Inspection on 24/07/07 for Down Hall Residential Home for the Elderly

This inspection was carried out on 24th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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Oak Ridge

Sun Court Nursing Home

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Down Hall Residential Home for the Elderly Down Hall Road Bradwell On Sea Southminster Essex CM0 7QP Lead Inspector Neal Cranmer Key Unannounced Inspection 24th July 2007 09:00 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 Down Hall Residential Home for the Elderly DS0000068093.V347265.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. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Down Hall Residential Home for the Elderly Address Down Hall Road Bradwell On Sea Southminster Essex CM0 7QP 01621 776509 01621 776700 downhallcare@tiscali.co.uk For e-mail contact refer to the homes internet website addr Mansion House Retirement Home Ltd 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) Simon Patten Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 20 persons) 13th June 2006 Date of last inspection Brief Description of the Service: Down Hall is a large period detached property set in a rural position approximately a quarter of a mile from the village of Bradwell. The home is set within three acres of private grounds and provides ample space for parking at the front of the property. Down Hall is registered to provide care to twenty elderly people (over the age of sixty-five). The properties rural location lends itself to providing a peaceful and relaxing environment. A bus service stops close to the home, which provides a link to the railway station in Southminster and local towns, including Maldon and Chelmsford. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced key inspection of Downs Hall, which took place on the 24th July 2007. During the course of the inspection twenty-four of the thirty-eight National Minimum Standards were inspected, of these one was not applicable, four were minor shortfalls, with the remainder being met. The inspection included discussions with three residents, the registered manager their deputy and members of the care team. A tour of the premises was undertaken which included all areas of the home, as well as this tour a range of documentary evidence was examined. The judgements made within this report are based upon evidence found on the day of the site visit, along with information provided from surveys returned from residents and other interested parties. What the service does well: What has improved since the last inspection? Since the previous inspection of the service an appointment to the post of registered manager of the home has been made. Documentary evidence required by regulation for the protection of residents has been improved. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs will be appropriately assessed prior to an admission to the home. The home does not provide intermediate care. EVIDENCE: Sampling of residents records evidenced that their needs were adequately assessed prior to admission to the home, with part of the assessment information being taken from the Community Care Assessment (COM 5) received from the referring social work team, this was then seen to be supplemented from an assessment report following a visit to the prospective resident from the home manager. This information is then used to formulate an initial care plan for the resident. Discussion with the registered manager indicated that the home continues not to provide intermediate care. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 9 Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect their needs to be clearly identified within their plans of care, and that their healthcare needs will be well met. The home’s practice relating to the storage of medicines needs to be improved to ensure that residents are adequately protected. EVIDENCE: Records sampled indicated that resident’s health, personal and social care needs were identified within their plans of care, and were reviewed at regular intervals. Entries in resident’s daily records were meaningful and appropriate indicating that staff had a good understanding of the needs of individuals. The services of healthcare professionals were brought into the home as and when required, this was confirmed during discussion with residents who spoke of staff being quick to arrange visits from healthcare professionals when needed, they spoke of District nurse and chiropodists visiting regularly. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 11 Discussion with a number of residents indicated that they were treated with respect by staff at all times, as did the observation of staff going about their duties, and their interactions with residents. Staff were seen and heard to be courteous, caring and professional in all of their dealings with residents, two residents spoke of staff always being very polite and respectful. Resident’s records sampled and discussion with the registered manager indicated that no residents were taking responsibility for their own medicines at the time of the inspection. The home’s medication policy and procedure protected residents. All medicines are administered only by staff who have been trained to do so, records sampled were in order with no gaps or omissions noted. Storage of routine medicines was in order, however the storage of controlled medicines was not, although the registered manager pointed out that the purchase of an appropriate cabinet was in hand. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that the lifestyle experienced in the home will match their expectations in respect of meeting their social and recreational interests, both within the home and in the wider community, and to be supported to maintain links with their families and friends. Residents can be assured of being provided with a diet that is healthy and wholesome. EVIDENCE: There continues to be no formal programme of activities at Down Hall, although a range of activities were available to residents. Activities continue to be decided on a daily basis in consultation with the resident’s, feedback was that quizzes continue to be popular. Discussion with resident’s provided evidence that people living in the home felt that the activities on offer were enjoyable, and many had opportunities to visit the local shops and pubs either alone, with relatives or in the company of staff. The registered manager spoke of the intention for the not to distant future to appoint an activities co-ordinator link person. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 13 Discussion with resident’s indicated that meals provided by the home were very good, both in terms of the quality and the quantity, although choice was a little limited, with the only real choice being at tea time. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home has in place sound policies and procedures for their protection, and that any complaints or concerns raised would be listened to and acted upon. EVIDENCE: Discussion with the registered manager indicated that their have been no complaints made in respect of the home since the last inspection, the home has in place the statutory local authority’s adult protection guidelines which provided clear definitions of the types of abuse that may occur along with guidance on the actions to be taken if an incident of abuse was alleged or suspected. The Department of Health practice procedures and guidelines regarding POVA (protection of vulnerable adults) were available in the home, and all staff have received training in adult protection. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home is generally comfortable and well maintained. (see main text for further comments). EVIDENCE: An environmental tour of the home was undertaken which evidenced that the home was currently in a state of upheaval whilst extensive building work was being undertaken to improve the overall environment. Discussion with resident’s indicated that the impact of this work on them was being kept to the minimum, and they were kept informed of what was going on, despite the implications of this work the residents were well aware that it was ultimately for their benefit. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 16 The registered person will need to monitor closely the impact of the building work on both the resident’s and staff to ensure that any risks posed are kept to a minimum. The home’s laundry facility was basic, but never the less adequate to meet the needs of the resident’s and is due to be improved greatly as part of the building work that is being undertaken Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be supported by a team of staff who are competent and well trained, and who are closely managed, residents can further expect to be protected by the home’s robust recruitment practices. EVIDENCE: As at the previous two inspections the home’s staffing rotas show that staffing levels are being maintained at three carers on duty during the daytime, with nights being covered by two waking night staff. Separate and additional staff are employed to cover cooking and cleaning duties. Staff recruitment records sampled evidenced that all necessary preemployment checks were undertaken prior to staff commencing work at the home, and that induction of new staff is conducted through the use of a workbook signed of by the manager over the period of the induction. Staff observed and spoken with during the course of the inspection showed a good understanding of the needs of the resident’s and were positive in their approach and attitude to their work. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 18 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect the home to be run by a person who is competent to do so and in their best interests, ensuring their financial interests and health and welfare are safeguarded. EVIDENCE: The home’s registered manager is not qualified to N.V.Q level four in management, although the deputy manager who takes responsibility for most of the day to day running of the home is, it was reported by the registered manager that an application is to be made to the Commission for Social Care Inspection for the deputy manager to become the registered manager. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 19 Discussions with resident’s and staff provided evidence that the home is run in the best interests of those living at Down Hall, resident’s spoken with stated that they were happy with the way that the home was run and that their needs were well catered for. Staff working at the home are now receiving formal supervision on a three monthly basis, the manager was reminded that staff need to receive formal supervision at least six times a year to comply with the national minimum Standard. The manager reported that the home does not manage any monies on behalf of residents. Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 20 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 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 3 X 3 X 3 2 3 3 Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes. 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 OP9 Regulation 13 (2) Requirement Timescale for action 30/09/07 2. OP19 23 (2b) 3. OP36 18 The home must ensure that controlled medicines are stored safely and securely, to ensure that residents are adequately protected. Provision must be made to 30/09/07 ensure that the home is kept in a good state of repair both internally as well as externally (this is particularly important whilst the building work is ongoing, to ensure the protection and safety of residents). Provision must be made to 30/09/07 ensure that all staff receive formal supervision on at least six occasions each year (every two monthly) This is a repeat requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000068093.V347265.R01.S.doc Version 5.2 Page 22 Down Hall Residential Home for the Elderly Standard Down Hall Residential Home for the Elderly DS0000068093.V347265.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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