Care Home: Deepdene House

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What the care home does well Not assessed on this occasion. What the care home could do better: Staff must ensure that they confirm the identity of all visitors including visiting professionals before allowing them access to the home. This will further ensure that people living in the home are protected. A risk assessment and policy for locking the office door must be developed to show how people are able to exercise their rights within the home and the reasons for any limitations. A copy needs to be sent to us on completion. Inspecting for better lives Random inspection report Care homes for adults (18-65 years) Name: Address: Deepdene House 55-57 Stanthorpe Road Streatham London SW16 2EA The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Claire Taylor Date: 1 7 1 0 2 0 0 8 Information about the care home Name of care home: Address: Deepdene House 55-57 Stanthorpe Road Streatham London SW16 2EA 02087696297 02089162301 ludmila.iyavoo@deepdenecare.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Deepdene Care Ltd care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia 20 Over 65 5 Conditions of registration: The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 20 Date of last inspection Brief description of the care home Deepdene House is a private care home that at the time of this inspection provides up to 20 places for adults with mental health problems and aims to rehabilitate them. The home is made up of 2 interconnecting Victorian houses with a large rear garden. There is parking at the front of the houses and on street. Accommodation at the present time is both single and double rooms. Deepdene House is situated in a quiet suburban street within easy walking distance of Streatham High Street, which has good transport links as well as leisure, community and shopping amenities. Care Homes for Adults (18-65 years) Page 2 of 10 Care Homes for Adults (18-65 years) Page 3 of 10 What we found: This unannounced inspection was carried out following some concerns raised by the local social services. We received information that there was a lack of staff on duty, that staff locked themselves in the office and allowed people to enter the home without checking their identity. We also sent a safeguarding alert to the local authority and any findings from their investigation will be included in the next report for this service. The inspection lasted approximately one hour and was facilitated by the operations manager who arrived at the home during our visit. We looked at duty rotas, spoke to staff and met some of the people who live in the home. Prior to the visit, we were notified that the registered manager had been dismissed and that Victoria Smith, Operations manager was temporarily running the home. On arrival at the home, staff did not ask for any form of identification and we were able to walk in. This was discussed with the acting manager and the member of staff concerned. We saw that there were four care staff on duty and a shift handover took place during our inspection. An agency cook was also preparing a meal in the kitchen and a relative was visiting at the time of our visit. The acting manager advised that there were 18 people living in the home with 2 vacancies. We looked at staff rotas for the months of September, October and November. These were clearly written and showed that there is a minimum of two staff on each day shift with one waking night staff and additional sleep in. Rotas also showed that on some days, staff work a middle shift from 9.30am to 5.00pm so that they can support people with their planned activities or routines. The home also employs additional ancillary staff for administration, housekeeping and domestic duties. At our last inspection in December 2007, we found that the home had experienced some staffing issues and that there had been a high turnover of staff. This resulted in an increased level of staff vacancies and ongoing recruitment drive. We therefore made a requirement that the home ensure sufficient staffing levels to meet the needs of the people who live there. Since that time, the acting manager advised that more staff have been appointed and that there were now only 2 vacant posts, one for a full time support worker and the other for a home manager. The rotas we saw reflected a consistent staff team with occasional use of bank staff to cover the vacancies. The operations manager explained that the organisation had also made changes to its recruitment practices. A Director for Human Resources was employed in January this year to review and strengthen the recruitment and selection process. This will be assessed at the next inspection of the service. We had a brief walk round the ground floor of the house and saw one staff with some of the people who live in the home. Three other staff were in the office to carry out the daily handover from one shift to another. Staff used a key to enable people to access the locked office. Staff reported that the lock on the office door was faulty and they were awaiting repair. It was not clear if people living in the home are able to freely access the office as one individual relied on staff support to enter. Such restrictions could be construed that people are not fully able to exercise their rights within the home. A risk assessment and policy for locking the office door is therefore needed. During our visit, we saw that staff used a two way communication system to speak to one another while one was in the office and a second was in another room in the house. This means that the home has measures in place for staff to summon assistance when necessary. What the care home does well: Care Homes for Adults (18-65 years) Page 4 of 10 Not assessed on this occasion. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action 1 1 5A(2)(a)&(b) & 5B(2). The registered provider must 30/04/2008 ensure that as required by regulation a break down of fees charged by the home is detailed within the homes service user guide. The registered person must 31/05/2008 review the arrangements regarding the programme of activities in the home, including how service users are consulted about activities, and how group activities can be arranged. Consideration must be given to identify funding to support this. (Previous timescales of 01/02/06 & 01/07/06 not met). The registered person must 31/05/2008 ensure that the menu is reviewed in consultation with service users to obtain their individual preferences and views and that meals are provided which are nutritious and varied and in adequate quantities. The registered person must ensure that that all staff adhere consistently to medication policies and procedures specifically that 31/05/2008 2 14 16(2) n 3 17 16(2)(i) 4 20 13(2) Care Homes for Adults (18-65 years) Page 6 of 10 all staff ensure that medication is administered to service users prior to signing medication records. Also, that for those service users self administering that weekly spot checks as specified are carried out and these are recorded. 5 28 23(2)(b)&(c) The registered person must 30/06/2008 ensure that the flooring in the communal lounge for smokers is repaired or replaced and that the sofas are replaced as part of maintaining the environment of the home to an acceptable standard for service users. 6 34 19 & Sched 2 The registered person must 31/05/2008 ensure that as part of recruitment and to protect service users that any gaps in employment are addressed with prospective employees and reasons given are recorded. This information should be kept in staff files. 18 (1)(c) The registered person must ensure that all staff receives training in respect to mandatory topics and this is updated as required to ensure service users? individual and joint needs can be met. 31/05/2008 7 35 8 39 24 The registered person must 31/05/2008 ensure that where customer satisfaction surveys are completed with service users the results of these surveys are complied in a report and made available to service users and other interested Page 7 of 10 Care Homes for Adults (18-65 years) parties including CSCI. A development plan in which identified aims and outcomes for service users are outlined should also be drawn up. 9 42 37 The registered person must 31/05/2008 ensure that where incidents occur in the home that relate to regulation 37 that these are reported to CSCI and other relevant parties. Care Homes for Adults (18-65 years) Page 8 of 10 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 12 A risk assessment and policy 31/12/2008 for locking the office door must be developed. A copy needs to be sent to us on completion. To show how people using the service are able to exercise their rights within the home and the reasons for any limitations. 2 33 12 Staff must ensure that they confirm the identity of visitors and professionals before allowing them access to the home. This will further ensure that people living in the home are protected 31/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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