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Inspection on 08/10/09 for Downs Cottage

Also see our care home review for Downs Cottage for more information

This is the latest available inspection report for this service, carried out on 8th October 2009.

it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Downs Cottage The quality rating for this care home is: The rating was made on: two star good service 2 8 0 8 2 0 0 8 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 review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Patricia Collins Date of this annual service review: 2 7 0 8 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: 183 Great Tattenhams Epsom Downs Epsom Surrey KT18 5RA 01737352632 01737371068 care@downscottage.co.uk www.downscottage.co.uk. Mrs N Thomas,Mr D Thomas Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 23 23 0 0 0 23 The maximum number of service users to be accommodated is 23 The registered person may provide the following category of service: 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 category; Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) Old age, not falling within any other category (OP) Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Change to registration certificate to make it clearer and easier to understand, removing conditions that are no longer needed. 2 8 0 8 2 0 0 8 Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Annual Service Review Page 2 of 7 Downs Cottage is a care home with nursing for older people including people with dementia and mental disorders. The providers are qualified nurses and are directly involved in the homes management and operation. This two-storey building has been converted and extended over the years. The domestic style and character of the building has been preserved. Car parking facilities are provided and a spacious, enclosed garden with ramped access to a furnished patio. Bedroom accommodation is on the ground and first floor and part accessible by chair lift. Most bedrooms are for single occupancy though some shared rooms are available. Most have en suite facilities and all have wash hand basins and emergency call bells. Communal living areas are on the ground floor and comprise of a combined lounge/dining room and separate lounge. Assisted bathing facilities and hoists are available. The home is within walking distance of shops and other community amenities in the village of Tattenham Corner village. It is served by public transport. Fees range from 551 to 897 pounds per week. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information we have received or asked for since the last key inspection. This included: An annual quality assurance assessment (AQAA) sent to us by the registered manager who is also one of two business partners. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It provides quantitative and numerical information about the service; also an assessment of services against the National Minimum Standards (NMS) outcome areas, demonstrating both areas of strength and where improvements can be made. Survey questionnaires were sent to the home for distribution to identified people using services and their representatives, staff and professionals who have contact with the home, inviting feedback about service provision. Unfortunately these went out late and none were received back at the time of carrying out this review. Information we have about how the service has managed any complaints or allegations received since the last inspection. What the homes management has told us about things that have happened in the service; these are called notifications and it is legal requirement to inform us of these events. The last key inspection report. What other people have told us about the service. Telephone contact with the registered manager/provider. What has this told us about the service? The completed AQAA was received on time. The content was clear, of good quality and validated by evidence. It supplied all the information asked for. This informed us that the homes operation and care practice continues to be underpinned by best practice principles and risk assessment processes are understood. Needs assessments and care plans focus on achieving positive outcomes for people using this service, ensuring facilities, staffing and specialist services meet individual needs. Independence and choice is promoted and an appropriate activities programme is organised, incorporating some activity sessions by peripatetic activity workers. The rights of people using services are safeguarded by robust policies and procedures, ensuring non discriminatory practice. Equality and diversity is recognised and embedded in the homes culture, underpinning staff recruitment and training, needs assessments, care practice and provision for meeting dietary and spiritual needs.The home promotes and maintains the health of people using services, ensuring access to health care services. Links exist with health and other relevant professionals and agencies. There is an efficient medication policy which has been reviewed and strengthened, following an incident. Annual Service Review Page 4 of 7 The home has a good record of staff retention and staffing levels continue to be monitored. There is high commitment to staff training and development, providing a skilled and competent workforce, to the benefit of people using services. Since the last inspection a further seven health care assistants attained qualifications in health and social care, at levels 2 or 3, as part of an ongoing National Vocational Qualification (NVQ) programme. A further five anticipate completing the NVQ programme by the end of the year. Care staff not working towards NVQ qualifications and nurses have received all statutory training and refresher training. Quality assurance systems are inclusive, ensuring a high standard of services and care. The homes management has responded to feedback from people using services and their representatives by introducing more variation into menus and redecorating areas of the home, including bedrooms. Developments since the last inspection include review and updating of policies and procedures, reflecting new legislation and current guidance. Change to the care of the dying policy and procedure has enhanced practice. The home is implementing advanced care planning specific to end of life care. The frequency for monitoring care documentation has been increased. Other improvements have enhanced the appearance and safety of the environment. A phased work programme is in progress for upgrading all fire doors. Hot water thermostats have been tested throughout the premises and repaired or replaced, as necessary. Colour coded signage and other orientation cues in the environment have been introduced, to aid independence. The carpet in the hallway has been replaced, a new stair lift installed and a portable wheelchair ramp has improved access to the garden. The homes complaint procedure is prominently displayed and has been issued to relatives and advocates of people using services. The home has not received any complaints since the last inspection. Robust policies and procedures are in place for safeguarding people using services from harm and abuse. Staff are trained to recognise and appropriately respond to indicators of abuse. There has been one safeguarding adults referral since the last inspection relating to an incident. Feedback from care management confirmed the home managed this well and no action was necessary by the safeguarding team. Since the last inspection a manager has been appointed and is subject to a probationary period of employment. This development has not changed the roles or involvement of the providers. The homes management continues to let us know about things that have happened since our last key inspection. In conclusion, people using the homes service continue to benefit from a well managed home. Their best interest is at the core of all management, care and support practices, ensuring their health, safety and welfare. What are we going to do as a result of this annual service review? It is our judgment, based on all available information, that the home is continuing to provide good quality outcomes for people using services. We are not going to change our inspection plan and will carry out a key inspection by 28th August 2010. However we can inspect the service at any time if we have concerns about the quality of the service or safety of the people using the service. Annual Service Review Page 5 of 7 Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: 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 copy of the findings 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. 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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