Care Home: Deepdene Care Centre

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What the care home does well Prior to the site visit the home`s manager had completed an AQAA and returned this to CSCI. He felt the home provided high quality care in a bright, modern, spacious, purpose built home. He said that he sees as many residents as possible each day and that he has an open door policy. This was confirmed during this visit as all the residents that saw him chatted comfortably with him and they obviously knew one another well. Staff spoken to during this site visit confirmed that regular meetings are held with the manager and that there is good communication within the home. All people are assessed prior to moving into the home and so they can be assured that their needs will be met. The care plans observed on the day were clear and well written. All had risk assessments in place and all documentation had been reviewed and updated. The activities in the home take place regularly in the home and the residents spoken to on the day were complimentary about the activity organiser and the events that were organised. What has improved since the last inspection? No requirements were made following the last inspection in 2006. The manager states in the completed AQAA that the home has received very positive feedback from the relatives and stakeholders regarding the quality of care provided. The gardens have been improved with the development of garden areas and landscaping. The manager has promoted safeguarding adult procedures to the staff and use visual materials around the home to support the teaching. What the care home could do better: No requirements were made as a result of this inspection. One recommendation was made that the home ensures they speak to their staff about the clothes that they wear to work to make sure that infection control procedures are maintained. CARE HOMES FOR OLDER PEOPLE Deepdene Care Centre Hill View Reigate Road Dorking Surrey RH4 1SY Lead Inspector Lesley Garrett Unannounced Inspection 14th February 2008 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 Deepdene Care Centre DS0000065717.V357984.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. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deepdene Care Centre Address Hill View Reigate Road Dorking Surrey RH4 1SY 01306 732880 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) Life Style Care (2005) Plc Mr William Greenshields Jones Care Home 66 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 66. Date of last inspection 23rd May 2006 Brief Description of the Service: Deepdene Care Centre is situated close to Dorking town centre and the local amenities. It was opened in January 2006 and is owned by Life Style Care PLC. It is a two-storey building with a total of sixty-six bedrooms and all are single with en-suite facilities. On each floor there is communal bathrooms, two sitting rooms and a dining room. There is a lift to access the upper floors. The grounds are well maintained with some CCTV cameras for security and there is a small car park for visitors. The fees for the home are £795 per week. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. The registered manager for the home represented the service. The inspector arrived at the service at 09:30 and was in the home for seven hours in total. The inspection was a look at how well the home is doing. It took into account information provided by the home’s previous manager and information that CSCI had received since the last inspection. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the care plans, daily records and risk assessments, medication procedures, staff recruitment folders, staff training records, and health and safety records. The home has submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection. No surveys had been sent to the residents prior to this site visit. No complainant had contacted the Commission with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the residents in the home and the staff for their time, assistance and hospitality during this inspection. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements were made as a result of this inspection. One recommendation was made that the home ensures they speak to their staff about the clothes that they wear to work to make sure that infection control procedures are maintained. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service only move in following an assessment and feel confident the home can meet their needs. EVIDENCE: The manager stated that he visits all prospective individuals before they move into the home. The home does not have a deputy manager at present but previously this assessment was completed by this person also. People currently using the service confirmed that they had been visited prior to admission whilst they had been in hospital. Assessments were also in place for those individuals admitted through the Care Managers. The AQAA advises that all prospective individuals are invited to visit the home and may also have a trial admission prior to making a decision about admission. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 10 The home does not provide beds for intermediate care. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health and personal care that individuals receive is based on their individual needs. Respect, privacy and dignity are maintained at all times. EVIDENCE: Five care plans were sampled and these were found to be well documented and contained the medical, social and personal care needs for each individual. The plans and risk assessments had been reviewed monthly and there was evidence of consultation with each individual or their representative where necessary. Individuals that were spoken to confirm that they had been consulted about their care needs and a relative also stated that they had seen the care plans for their relative. Suitable risk assessments are in place for all areas of the individual’s daily life in order to promote independence whilst ensuring the person’s safety and wellbeing. Risk assessments in place included moving and handling, nutrition Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 12 and skin integrity. Daily care records were professionally written and maintained to reflect the individuals needs and care provided. The care plans evidenced that regular and appropriate health care appointments are attended and the General Practitioner (GP) visits the home each week and when necessary. Through sampling care plans it was evident that the home has maintained good working partnerships with health care professionals, which include visits from opticians, dentists, chiropodists, physiotherapist and specialist palliative care nurses. One individual confirmed that they had seen the GP recently and that they only had to ask the nurse if they wanted a visit. The nurse showed the inspector that the home has good, clear procedures in place for the monitoring and recording of all medicines administered and those entering and leaving the home. Staff training in medication has been conducted and a medication audit takes place every month. Staff were observed providing personal support to residents in such a way that promoted and protected the individuals privacy and dignity. Throughout the day the inspector observed that clients were addressed in a polite and courteous way by staff. One individual stated ‘the staff always knock on my door before entering. They are very polite and nothing is too much trouble’. Signs are available for the bedroom doors if the individual does not wish to be disturbed. The AQAA states that the home has a ‘dignity in care’ audit that is carried out twice a year. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lives and recreational activities meet their expectations. EVIDENCE: The home has a lounge on each floor and the inspector was told that the activities take place on the different floors depending on the type of activity. There was a programme displayed on each floor so that individuals, relatives and staff know what is planned for the day. One relative commented during the site visit that it would be helpful for the programme to contain the date next to the day. The activity organiser thought this would be a good idea. Examples of the activities on offer included art sessions, beauty days, light exercises and cooking. The AQAA stated that the activity co-ordinator spends one to one time with the individuals using a person centred approach to devise an individual activity programme. The activity programme was seen in the care plans and these had also been reviewed. On the second floor a sensory room is available for those individuals who wish to use this room, which the Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 14 manager stated, helped to give a feeling of calm and well being to some individuals. The activity co-ordinator spoke with the inspector and said she had only been in post for two months but had previously worked as a carer. The people who use the service were complimentary about her and said ‘the activity lady is really good we all enjoyed the quiz afternoon the other day’. ‘The activity coordinator took me for a walk into town we walked around the church’. Another said ‘She is very kind and caring’. The manager stated that relatives are encouraged to visit at any time and some past relatives are now volunteers in the home. On the day of the site visit one volunteer was seen sitting with an individual having lunch. The local priest and vicar visit the home to administer Holy Communion and their family takes one person to church. The people who use the service stated that the staff are always giving us choices they said they ask if we want to get up if we want to go to bed and what we want to eat. The manager stated that ‘every job is an activity we ask them everything’. The manager stated that meal times have become a protected activity. This means that relatives or visiting professionals are asked to avoid meal times. Domestic staff have been asked not to clean in the dining areas at this time. The manager also stated that they felt that the individuals have benefited from this approach as most of the weights recorded showed that the residents were either maintaining their current weight or gaining weight. One resident said ‘the food is wonderful. I shall be putting the three stone back on that I lost in hospital’. ‘We get a choice and if you don’t want it they can always offer something else’. Another resident said ‘the food is very good but the portions are sometimes too big and I don’t like to waste it’. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected by the homes complaints and safeguarding adults procedures. EVIDENCE: The home has an established complaints procedure. The manager advised that all complaints received by the home are fully investigated and the records kept by the home evidenced this. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Some of the individuals living at the home and visitors told the inspector that they were confident that the manager or staff would deal with any concerns or complaints they may have. Records sampled indicated that staff had attended safeguarding vulnerable adults training and for newly recruited staff this had been included in the induction programme and ongoing training provided by the home. The manager stated that the senior team in the home had not received recent local authority training but this was arranged during the site visit. The manager demonstrated a good knowledge of these procedures and had contacted the local authority for information leaflets, which he had distributed to all staff. Both Criminal Record Bureau checks (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 16 Staff spoken to on the day of the site visit were clear about their responsibilities concerning a safeguarding incident and knew who and how to report a concern. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The design and layout of the home enables people to live in a safe wellmaintained and comfortable environment. EVIDENCE: The home was built in 2005 and opened in 2006. It has a ground, first and second floor. On each level there are two lounges and a dining room. All bedrooms are single en-suite and have been personalised. All assisted toilet facilities are situated close to the communal areas for the comfort of the people who use the service and there are plenty of assisted bathrooms on each floor. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 18 The dining rooms have good facilities for the individuals to sit and eat meals in comfort with the tables prepared for lunch with tablecloths and napkins. Individuals spoken to on the day of the site visit confirmed that they liked their rooms and felt comfortable with their possessions around them. On the day of the site visit it was observed that staff do not wear uniforms. One cleaner was observed to be wearing a long sleeved cardigan underneath a plastic apron. A discussion took place with the manager about infection control and he stated that the uniform policy was under review at the moment. The staff that we (the commission) spoke to all said that they would prefer to wear a uniform and one carer spoken to had bought her own tunic. A recommendation will be made at the end of the report for the home to speak to all staff about infection control procedures when wearing their own clothes. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and skilled and in sufficient numbers to support the residents in the service. EVIDENCE: Staff rotas were observed and the manager said that he completes dependency levels for all residents every month and this determines the number of staff for each floor that he needs. There is a registered nurse on each floor per shift and the rotas confirmed this. The manager also said that the rotas are discussed every day with the staff in the afternoon and at this meeting the next days allocation is completed so that as soon as the staff arrive the next morning they know where they are working. The residents that were spoken to on the day of the site visit were complimentary about the staff at the home. One resident stated ‘staff are excellent. They listen to you and get what you want and need’. On the day of inspection the training co-ordiantor was on duty and explained the training that is organised for the home. All new staff receive an induction to the home, which is carried out by a training company. All staff also receives Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 20 mandatory training, which includes health and safety, food hygiene, manual handling, fire and safeguarding adults. The training co-ordiantor stated that seven staff have the National Vocational Qualification (NVQ) at level 2 and two of these members of staff are now studying for their level 3 qualification. The NVQ training within the home is on going with more planned for the staff later in the year. Three staff recruitment folders were sampled and they all contained the necessary information required to safely employ staff in the home. This practice ensures that the residents are protected from harm. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect and has an effective quality assurance system in place. EVIDENCE: The manager has been in post for six months and has been registered with CSCI. He was a manager of a home prior to this post and has a background in elderly care. He said that he attends regular training sessions to ensure that his knowledge is current and that he is currently working to complete his registered managers award. Staff that were spoken to stated that the manager was approachable and that meetings took place every afternoon with the Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 22 registered nurses but that you could approach him at any time and he has an open door policy. The manager said the home carries out yearly surveys of its residents and relatives. They are returned to their head office and the results are they sent to the home. The manager then compiles an action plan to deal with any shortfall or problems that these surveys highlight. The home also holds meeting with the residents and relatives every three months and minutes are kept. One relative said on the day of the site visit that she had made some recommendations at the last meeting and were hoping these would be implemented. The regional manager who was also at the home on the day of the site visit confirmed that she does monthly visits to the home and these were available to be seen in the office. Also quality monitoring visits take place and these too are all documented. The administrator looks after any personal allowance accounts for the residents. She keeps a record of all transactions and all receipts are kept but no cash is kept at the home; it is all banked. The home does have some petty cash for residents use in an emergency. The home benefits from a full time maintenance person who is responsible for the fire alarm test every week and water temperatures. These recordings are all clearly documented. Certificates were in place for the gas appliances, electrical circuits, fire equipment and emergency call equipment. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. 1. Refer to Standard OP26 Good Practice Recommendations It is recommended that management make sure that staff wear suitable clothing to ensure that infection control procedures are followed, as the home do not provide uniforms. Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Deepdene Care Centre DS0000065717.V357984.R01.S.doc Version 5.2 Page 26 - 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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