Inspection on 03/08/09 for Downhurst

This is the latest available inspection report for this service, carried out on 3rd August 2009.

CQC found this care home to be providing an Excellent service.

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

Downhurst 22/09/06

Downhurst 31/10/05

Downhurst 21/04/05

Downhurst 16/08/04

Downhurst 05/05/04

Downhurst 18/11/03

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 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Downhurst 76 Castlebar Road Ealing London W5 2DD Lead Inspector Ms Jane Collisson Key Unannounced Inspection 3rd August 2009 10:00 DS0000027702.V376921.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downhurst Address 76 Castlebar Road Ealing London W5 2DD 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) 0208 997 8421 0208 810 9044 manager@downhurst.com Ealing Eventide Homes Limited Rea Banks Williams Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC 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 - Code OP The maximum number of service users who can be accommodated is: 26 6th September 2007 2. Date of last inspection Brief Description of the Service: Downhurst is a home for older people located on a busy road within walking distance of Ealing Broadway. There are buses to Ealing and Greenford, passing by the home, and the tube and mainline stations at Ealing Broadway and West Ealing are within easy access. The home was opened in 1948 and consists of a large detached period threestorey house with a large extension, built in 1951, to the rear. The buildings are joined by an interior walkway with seating overlooking the garden. The home is registered for twenty-six residents and its category of registration is old age. There are two lifts, one having been installed in 2009 at rear of the building, so all areas are now accessible. There are twenty four single rooms, with the one double room currently used as a single. There are no en-suites but there are five bathrooms, some assisted, and eight toilets. The home has one large lounge and a separate dining room in the main house, with two lounge/dining rooms in the rear building. There are other areas which can be used as quiet or private spaces. There are well-maintained gardens around the home, with places to sit, including a patio. There are several offices located throughout the building. One small room is set aside for residents who smoke. Downhurst is owned and managed by Ealing Eventide Homes Limited, a notfor-profit organisation. There is a board of Management. The home has a Registered Manager, Deputy Manager, five senior staff, and a team of day and night Support Workers. There is an administrator, a handy person, a gardener, two cooks, a kitchen assistant, laundry and domestic workers. The current fees are £510 - £680 depending on the size of the room. Downhurst DS0000027702.V376921.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. This unannounced inspection was carried out on the 3rd August 2009 from 10.00am to 5.15pm. An Expert by Experience accompanied the Inspector and stayed for three hours. The Care Quality Commission is trying to improve the way it engages with people who use services so as to gain a real understanding of their views and experiences of social care services. It now uses ‘Experts by Experience’ who are an important part of the inspection team and helps Inspectors to get a picture of what it is like to use a social care service. The term ‘Expert by Experience’ used in this report describes a person whose knowledge about social care services comes directly from their experience of them. The Registered Manager, who has been in post since December 2006, was present throughout the inspection. The Deputy Manager also came in to assist with the inspection and there were three care staff on each of the early and late shifts. The ancillary staff met included one of the cooks. We discussed the finances with the accounts officer. There were eighteen people in the home. Admissions had been suspended while the work on the lift was taking place but are being recommenced. We met most of the residents during the day. The Expert by Experience and the Inspector toured the home with the Registered Manager. The Expert observed the lunch and spoke to several more residents throughout the home. Her findings have been incorporated into the report. She said, in summary, “It was nice to spend some time in a home where you could feel the warm friendly atmosphere. It was nice to see staff members and residents interacting with each other and for the residents to seem concerned for each other’s welfare. The pleasant comfortable atmosphere within this home can only enhance the wellbeing of its residents and it was apparent that this was a home with a ‘heart’ which perhaps goes someway to compensate for the shabbier parts of the building.” During the day, the residents were playing a ball game, with one person keeping the scores. Bingo was held in the afternoon and a singer, accompanied by a pianist, then played popular songs, providing song sheets for the residents and staff, who joined in. There is a hairdressing room and Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 6 the hairdresser was in the home on this day. Those people who preferred to stay in their rooms are able to do so. A small number of people can go out unaccompanied and pursue their own interests. The Manager completed the Annual Quality Assurance Assessment from the Care Quality Commission, which provides a self-assessment describing the areas where the home does well, where it could do better, and its planned improvements. It also includes statistical information on residents, staff, training and maintenance. Questions are asked on equality, diversity, the meeting of cultural and religious needs, and the way in view the views of the people using the service are sought. The Manager provided us with all of the information we requested and we found it accurately reflected the contents of the Annual Quality Assurance Assessment. Samples of records examined on this inspection included care plans, recruitment, medication administration, training and maintenance files. The home has links with nearby churches and people from various denominations visit the home. No specific cultural needs were required to be met at the time of this inspection. The Expert by Experience wrote, “I spoke to many residents and every single one of them was very pleased to be living at Downhurst and in many cases had not looked at any other home. Having lived in the area for many years they all knew that Downhurst was were they wanted to be if the time came for them to leave their own property. The comments ranged from “the staff are so polite and so very kind”, “I like living in such a relaxed atmosphere”, “I know I can no longer live at home but this is almost as nice” we all get on quite well with each other” “we can come and go as we please providing we tell the staff we are going out” to “I think they deserve 10 out of 10”.” To get further views, we sent surveys to the people living in the home, and we had six returned. Six staff returned their surveys. We also had three from professionals who have contact with the home. The comments were all positive and we have included them in the body of this report. At the last inspection in September 2007, six requirements were made. Two have been made at this inspection in relation to the environment. The Management Committee need to look at prioritising the redecorating and refurbishment work to ensure a better standard in all parts of the home. The upgrading of the small rooms and communal facilities would benefit greatly the people living in the home. However, we found that, overall, the support to the people living in the home to be excellent and that people have a good quality of life. What the service does well: Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 7 We asked people who replied to our surveys what was good about the home and if there could be improvements. They said: “Everything, I am very happy”. “Nothing at moment, contented with my care and lifestyle. Makes people feel at home.” “They consider my well being” “Fully satisfied” “Well satisfied” People said that staff listen to what they say and act upon it. They said that they find the staff to always be “professional”. Staff who replied to our surveys said: “Training for support for staff for further educational and personal development” “Activities, open door, well balanced meals, always clean and tidy” “The Manager has made many improvements” “Time to listen to residents and staff” “Comfortable and approachable” “Pleased with my job” “Treated well” “Home does well overall” “Safe environment” “Regular meetings” “Staff Training” “Provides a good level of service” Staff were positive about having up to date information, a good induction and training opportunities, and regular support. They all felt that the home provides good activities, outings and entertainment for its residents. The professionals who visit the home said: “Downhurst provides client centred care” “The atmosphere within the home is always welcoming and friendly” “The team is friendly, efficient and supportive.” What has improved since the last inspection? People who live in the rooms to the rear of the home now benefit from the lift installed in 2009. A new care planning system has been introduced, which focuses on the resident as an individual person. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 8 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 9 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 Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have clear information to help them to make a decision about the home. People’s needs are thoroughly assessed before they are admitted to try and ensure that they choose the right home and efforts are made to ensure that people choose the home for themselves. People with physical disabilities can have their needs met. EVIDENCE: The home has updated its Service Users’ Guide and Statement of Purpose. These provide comprehensive information for the people to undertake the care and support that is offered. It has also prepared in a new Statement of Purpose in readiness for its application to be registered for dementia care. Copies of the information were seen in the bedrooms and the information on Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 11 the Charter of Rights, which has been updated, and the complaints procedure were placed inside people’s wardrobes so they are readily accessible. We did not see the contract or terms and conditions on this occasion but the Manager said these are available for each person in the home. The Manager or the Deputy Manager assess the people who wish to move to the home and a sample of the assessment procedure was seen. Although families visit, the Manager said that she requires people to see the home before making a decision, but will visit them initially in their home or in hospital if required. The Manager said people may visit as often as they wish before making their decision. The home has improved its facilities for people with physical disabilities by installing a lift at the rear of the building. This allows people to access the lounges, bedrooms and bathrooms on each floor. The staff have training in dementia care to support those people who have developed the illness, which is ongoing. There is no Intermediate Care facility in the home, so this National Minimum Standard could not be assessed. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are individualised and help staff to understand their preferences and the support they require. People have risk assessments and support to keep them safe and healthy. People have their health needs met by community services. Medication administration is good. People are treated with respect and staff are sensitive to people’s need for privacy. EVIDENCE: The home uses a pre-printed care planning system which has been developed since the last inspection. All of the information for each person, including risk assessments, is included in the one file. We looked at a sample of four plans and found that they contained all of the required information. A personal history of the person is included and, as well as the standard forms, the Manager has introduced a more person centred approach by including Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 13 photographs from the person’s past and current photos. This has the benefit of helping to understand the person’s past history, family and interests. One of the professional visitors to the home remarked on the “client centred care” in the home. The Manager is a health and safety trainer and the Deputy Manager trains moving and handling, so both have the knowledge to undertake risk assessments. People’s health needs are met by community medical and health services. People have a choice of general practitioners and those who have lived locally can retain their doctor. The care planning system has a form for recording all visits of the general practitioners, chiropody, optical, dental and other health needs. The home has made efforts to reduce and prevent the number of falls and has kept records to evidence this. There was limited involvement required by the district nurses at present and the Manager said that there are no incidences of pressure sores currently. One person is currently being nursed in bed and is turned regularly. The home has agreed it can meet the person’s needs at the present time. One of the health professionals who visit the home said team are “friendly, efficient and supportive” and both were positive about the all of the responses to our surveys. The current system of medication administration is through weekly sealed Nomad boxes, which are filled by the pharmacist and delivered weekly. The home is looking to move to a 28 days blister pack system but needs to have a room to store the medication. They have identified a room to convert for this purpose. The Deputy Manager checks the weekly boxes as they come in and the pharmacist prints the Medication Administration Record sheets. There are PRN (as and when) medications held, creams and items which cannot be placed in the boxes. We checked a sample of medication and found to be in order. We were informed that only senior care workers give medication and there have been no errors. In respect of privacy and dignity, we observed people being treated appropriately. The Expert by Experience wrote,” Whilst I was walking around I did notice members of staff knocking on residents’ doors which showed an awareness of and a respect for the residents’ privacy”. She also wrote, “I saw the residents being escorted into lunch and noted the staff whispering to each person before they were taken into the dining area. I was informed by one resident that the staff discreetly ask “if you need to go to the toilet” before they take you into lunch. I thought this was such a dignified Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 14 way of dealing with the matter and was very impressed by that as it maintained the residents’ dignity.” The Manager has identified an area for improvement in regard to people’s wishes about death and dying. The home does record people’s wishes in regard to funeral details but she is aware that this is an area where those people who may wish to discuss the subject further should be given the opportunity to do so. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a good quality of life by having opportunities to participate in arrange of activities, as and when they wish. The home is run to accommodate the residents’ preferences. Meals are varied and people have good choice. People have their religious needs met in the way they prefer. EVIDENCE: We found the people in the home are able to have opportunities to enjoy both activities within and outside the home. People confirmed to us that they enjoy these. Those that are able to follow their religious beliefs do so, and this includes visit to the local Ealing Abbey and ministers of religions going into the home regularly. There is an ecumenical service monthly. We observed on the day of the inspection an activity, and a singer and pianist entertaining the residents. Song sheets were made available by the singer and staff also joined in with the singing. A bingo session had also been held, and this and other activities are run by members of the management committee. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 16 The singer goes regularly to the home and they also have other entertainers as the residents particularly enjoy music. Events are advertised and we saw examples of these notices around the home. The Expert by Experience wrote, “On walking around the home I saw several residents joining in a ball game which was being organised by a member of staff and they were also singing. It was apparent that everyone was enjoying themselves. The activities programme seemed to be quite varied and I noticed there had recently been a trip to the seaside and that a local school had come in to sing for the residents.” The Manager said that all but four of the residents had been on the recent trip to Brighton. The home has its own mini-bus. The home has an annual event, the Downhurst Olympics, where the garden is utilised for games, with residents able to nominate staff to participate for them. This is an event which includes their family and friends. The Manager was hoping to make it more special by inviting an Olympic celebrity to this year’s event. Use has been made of several areas within the home where people may sit quietly, enjoying the garden, or meet with their visitors. People confirmed that visitors are welcome and they can stay for a meal, at a small charge. We found that people are free to exercise choice by choosing to stay in their rooms and choose where to sit. The Manager had, for a long time, planned to make more choice by changing the two main house lounges to accommodate both sitting and dining areas. However, after this had been tried, the residents decided they liked it better as it was before and it has now reverted the previous arrangement. We met with the assistant chef at this inspection. There was a meal of meatballs or omelette, with vegetables, at lunch time. The dessert was Eve’s pudding, yoghurt or ice cream. The details of the menu were recorded on a whiteboard which could be viewed by the residents. The Expert by Experience, after observing the lunch, said, “The home has a 4 week revolving menu which had a very varied choice on it and I did note that two residents had chosen something that was not on the menu at all. One gentleman said “the food is always good and you can have what you like”. I also noticed everyone being asked if they wanted seconds. Those members of staff that were serving lunch were polite and helpful and I noticed that anyone that needed help with their lunch was given it in a caring, unhurried, relaxed way.” Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 17 We saw the food available for the evening meal. There was a choice of spaghetti on toast, two varieties of soup, sandwiches and cakes. There were no special dietary or cultural needs to be met at the present time. One of the professional visitors to the home praised the way people are offered a pre-lunch drink, the delicious looking food, and the unhurried and relaxed atmosphere at mealtimes. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by staff training in safeguarding, and have the information to support them to complain if they wish to do so. People have the opportunity to vote. The home has an open culture which promotes people to have confidence in the making their views known. EVIDENCE: There have been no complaints in the home since the last inspection in September 2007. The complaints procedure is in the Service Users’ Guide and also in people’s rooms, inside the wardrobes, so that they are accessible to people and their families. There have been no complaints through the Commission for Social Care Inspection or Care Quality Commission. We saw a number of letters with compliments written to the home and its staff. The Expert by Experience wrote: “Every resident I spoke to was aware of how to complain if necessary and I was told by a resident “we are not afraid to speak up for ourselves” and another said “we say if something is not right and it is dealt with”. People who replied to our surveys said that they knew how to complain. There is a Charter of Rights which includes a right to complain. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 19 The Manager said people had been able to vote in the last elections in May 2009 and many had received postal votes. She has included, in the Charter, “The right to fully exercise citizenship rights such as your right to vote”. Staff have training in safeguarding adults procedures and there have been no issues raised. There is a Deprivation of Liberty assessment in each file and information can be recorded on the Mental Capacity Act if required. We discussed with the Finance Officer how the monies held on behalf of people are managed and audited. Only limited money is held for personal expenses such as hairdressing, newspapers and toiletries. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and homely but would benefit from upgrading in a number of areas. People have the opportunity to personalise their rooms but many are small. All areas of the home are now accessible. EVIDENCE: The home is located in a pleasant, residential area of Ealing, within easy reach of the facilities of Ealing Broadway. There are buses passing the door. The home is spacious and nicely furnished. There has been a programme of refurbishment but there are several areas which would benefit from decorating and replacement of fittings, such as the curtain rails. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 21 The Expert by Experience wrote, “I noted that the home, although clean and odour free, was poorly decorated in some areas and badly in need of some redecoration. I noticed that the curtains in the main lounge were falling off of their runners and this was the same in several of the bedrooms. I also noted that in some cases the radiator covers were not in a particularly good state of repair and bits of them were missing. The toilets, whilst clean, also needed some redecoration and the backs of some of the doors were very badly marked.” One of the professional visitors to the home, who returned our survey, felt that “since the home is very old, a number of adaptations and updates would improve the clients’ quality of life and make working conditions easier for the staff”. However, the person praised the cleanliness and homeliness of Downhurst. The Manager said that there is difficulty in getting the fittings for the curtain rails. Consideration must be given to replacing them if this continues to be the situation. We have made a requirement for the radiator covers to be repaired, both for safety against high surface temperatures and because residents might catch themselves on the loose areas. Since last inspection, a lift has been installed to the rear of the building which makes all floors accessible to people using the bedrooms, lounges and other facilities. The gardens surrounding the home are very attractive. The Expert by Experience said, “The gardens both at the front and the rear of the property were very well maintained and full of bright coloured flowers. The grassed area at the rear of the property was very well kept and the residents obviously appreciated the garden and can be quoted as saying “the garden is wonderful” “the gardener works so hard” “we love the flowers”. There had also been improvements to the kitchen, including new windows. Although the kitchen is kept clean by the staff, there were areas, including tiling and skirting boards, which should be undamaged. These will need to be renewed to ensure good hygiene can be maintained. The Management Committee should ensure that kitchen replacement is included in their development plans. An area outside of the kitchen window is in need of better weed control and regular maintenance to prevent any health hazards or infestation. The home intends to employ extra staff to cope with this. Although no rooms are en suite, there are five bathrooms, some with specialist equipment, and toilets throughout the home. While the facilities are clean and tidy, and some improvements have been made, they would nearly all benefit from upgrading in the not too distant future. One bathroom has been brought Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 22 back into use, since the last inspection, and the bath will be moved to accommodate a hoist. We saw a number of the bedrooms on our tour of the home. The bedrooms vary from very large, to a number that are around 8 square metres, which is under the National Minimum Standard and cannot contain the items which people should be offered. The Expert by Experience wrote, “Despite the fact that some of the residents’ bedrooms were quite small they had all been encouraged to bring their own furniture, personal mementos and ornaments thereby making their rooms more homely.” The home has some long term plans to enlarge some of the bedrooms. We found all of the areas we saw to be clean, pleasant and hygienic. One of the comments made to the Expert by Experience was that the laundry “works well” and “nothing seems to get lost” which was a positive response and of importance to the residents. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a well trained staff team. Staff have the opportunity to undertaken regular basic and specialist training. Management encourage staff to undertake further qualifications. Recruitment procedures are generally satisfactory. EVIDENCE: There were three staff on duty on the first day of the inspection, for the eighteen people currently residents. The usual staffing is four staff from 8am to 8pm when the home is full, and two at night. There is a staff team of fourteen permanent care staff and a small number of bank staff. Most staff have worked in the home for some time and provide good continuity for the residents. There are sufficient auxiliary staff to carry out the tasks, and these include a gardener, handyman and accounts assistant. It is planned that the home will take on apprentices for gardening and maintenance. We saw good practice by the management team by the Manager and Deputy Manager both covering weekends. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 24 The Manager provided us with a spreadsheet of the staff training courses. All of the staff have attended all of the basic courses, mainly in 2009, for moving and handling, infection control, health and safety, fire awareness, first aid, food hygiene and safeguarding. The Deputy Manager is a moving and handling trainer and the Manager is a health and safety trainer. The staff are participating in the Aged Care Channel, which a live interactive facility which allows staff to ask questions of specialists regarding dementia. The sessions can be recorded for future training. The level of National Vocational Qualification training is very good, with twelve staff having the qualification at Level 2 or 3. It is planned that all staff will achieve Level 3. Staff were very positive about the training the home offers. We examined four recruitment records. We found that they contained the required information. However, there were a small number of missing dates on the references and the staff who carry out the recruitment need to ensure that these are all recorded and checked. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37, 38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager had the experience and qualifications to provide good management and leadership. The home operates in an open and transparent manner. The home is well managed by experienced and qualified staff who work in the best interests of the residents. People are safeguarded by good systems and record keeping. People’s views are sought and acted upon. EVIDENCE: The home’s Registered Manager has many years’ experience of managing care homes and has the Registered Managers’ Award. She was previously a nurse. She has undertaken a 10 week course in “Transforming Lives” with Skills for Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 26 Care which has resulted in membership of the Institute of Leadership and Management. The Manager is involved in organisations, such as Skills for Care, and participates in Provider forums and other groups. This has enabled her to use her expertise in other organisations and develop her professional skills and knowledge. This is particularly useful as the home is not connected to any other care home. The Deputy Manager has achieved the National Vocational Qualification Level 3 in Business Administration and Management. We found that the home has an excellent atmosphere with the staff and residents enjoying a good rapport. We found the staff team to be friendly and approachable. People came to the Manager’s office during our visit and it was obvious this was not unusual and there is an “open door” policy. From the information we received in the home, we found that people are consulted about their support and the way in which they wish the home to be run. This was evidenced by the opportunity to make their wishes known about the changes to the communal areas. We were provided with a copy of the 2008/2009 report on the residents’ surveys. Downhurst commenced this monitoring system in April 2007. To quote from the report “To ensure quality satisfaction, from time to time, Downhurst still “dip tests” the service. This is done by using the National Care Association Quality Assurance Monitoring Tool. Each month random residents are asked up to six questions about one area of the service.” These results are analysed and action taken to address any concerns, perhaps with an individual if this is appropriate. The Management Committee continues to undertake thorough monthly visits, as required under Regulation 26 of the Care Home Regulations 2002. These include interviews with the residents and staff, the checking of records, activities and their impressions of the home. They also check accidents and incidents for the month. Many of the Committee spend time in the home, helping with activities and auditing. This gives them the opportunity to see, at first hand, the running of the home, so that the reports are based on continual observation as well. The questions asked include those regarding meals, activities and personal care. The report also includes the conclusion of the results of the surveys. The home only holds small amounts of money for people for their hairdressing, newspapers, and other small expenditure, which is paid into the account by people or their families. A separate book of expenditure and income is kept for each person and it is also kept on the computer system. The administrative officer showed us the system and said that it is audited by one of the Directors of the Committee. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 27 Most of the staff were seen to be supported by regular supervision and we saw samples of the supervision for 2009. We did not check the policies and procedures on this occasion, but the Annual Quality Assurance Assessment records that they were last updated in April 2009, or later. The records are well maintained, and the Manager provided us with all of those we required. The home has in place a thorough fire risk assessment dating from 2007. It is advised that it is reviewed annually as there have been changes to the home with the addition of the lift. We saw that monthly fire drills take place and one full evacuation has been carried out. We examined the maintenance records. The fire system was last checked in May 2009 and the London Fire and Emergency Fire Authority visited in August 2008. Different fire alarm points are tested weekly. The Legionella testing was carried out in February 2009. The gas and small electrical appliances checks were carried out in April 2009. Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 28 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 X X X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 4 18 4 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 3 Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 29 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. 1 Standard OP19 Regulation 23 Requirement The Registered Providers must ensure that the fittings in the home are kept in good repair and that items, such as the curtain rails and radiator covers are kept in good repair or replaced when repair is not appropriate. The Registered Providers must ensure that, to aid hygiene, all areas of the kitchen are easy to clean and surfaces are impermeable. Timescale for action 30/09/09 2 OP25 23 31/10/09 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 OP19 Good Practice Recommendations That the replacement or refurbishment of the kitchen and those toilets and bathrooms in need of refurbishment are prioritised in the programme of maintenance and refurbishment. That the Fire Risk Assessment is reviewed annually. DS0000027702.V376921.R01.S.doc Version 5.2 Page 30 2 OP38 Downhurst Downhurst DS0000027702.V376921.R01.S.doc Version 5.2 Page 31 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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 © (2009) Care Quality Commission (CQC). 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. 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