Inspection on 25/10/06 for Down House

This inspection was carried out on 25th October 2006.

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 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

Down House 13/09/07

Down House 02/02/06

Down House 06/09/05

Down House 22/02/05

Down House 14/07/04

Down House 04/12/03

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Down House Down House 277 Tavistock Road Derriford Plymouth Devon PL6 8AA Lead Inspector Doug Endean Unannounced Inspection 25th October 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Down House DS0000030358.V303431.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 House DS0000030358.V303431.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Down House Address Down House 277 Tavistock Road Derriford Plymouth Devon PL6 8AA 01752 789393 01752 769747 down.hs@btinternet.com mayhaven.co.uk Mayhaven Healthcare Limited 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) Vacancy Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability over 65 years of age (43) of places Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users can be admitted over the age of 40 years in relation to the PD category only. 2nd February 2006 Date of last inspection Brief Description of the Service: Down House is a Care home that is registered to take up to 43 service users of either gender, from the age of 40 years old, who require nursing care, and a maximum of 3 Service Users who require personal care only. The home is situated in the Derriford area of Plymouth close to Derriford Hospital, and is on a main bus route to Plymouth city centre. It is a large adapted old house with a modern, purpose built, single storey extension. The main house has two floors that have client accommodation with access to the first floor via a stair-lift. The home currently has no passenger lift, but the first stage of the new extension is very near completion and this incorporates a shaft lift that will stop at each floor that clients are accommodated on. The home is tastefully decorated and the furnishings are of good quality. There is good provision of equipment for the disabled and those needing support such as a wheel in large shower room, a good sized disabled bathroom, mobile hoists and en-suite facilities to most bedrooms. Externally there is a well-maintained patio and garden area that has a mix of shrubs, and gravel areas with attractive pots for plants. Once the first stage of the extension is complete the garden to the side of the home will be reinstated offering an extensive level lawn area accessible by a ramp from the new dining room that is a part of this development. The Registered Managers post is vacant and the home is advertising to recruit a suitably experienced individual. The homes fees commence at £326 for residential care and £490 for nursing care. In addition service users will pay for such things as hairdressing, personal telephone line and newspapers they have ordered for themselves. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first unannounced Key inspection. It took place on the 25th October 2006 at 10:30 hours and lasted a total of five hours. The Registered Individual accompanied the inspector for the majority of the inspection and provided a valuable contribution to the process. The inspection included a tour of the building, discussion with four service users and three staff. Four service users records were looked at and four staff files were read. The main meal was served during the inspection and the inspector obtained views of some service users about the food that receive. The Administrator provided her assistance in looking at staff files, training information and other records. Prior to the inspection the views of visiting professionals and relatives were given about their experiences with the home. The home provided the inspector with a completed pre-inspection form and other information that demonstrated the degree of training that has been done, the number and qualifications of staff that are employed and the maintenance that has been completed. What the service does well: What has improved since the last inspection? The building work is nearer completion. The previous inspection identifies that the carpet in the corridor needed attention. This has been replaced with a new carpet. Down House DS0000030358.V303431.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 House DS0000030358.V303431.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 House DS0000030358.V303431.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): The homes performance was assessed against Standard 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does gather comprehensive information about prospective service users that enables them to make an informed about the suitability of an admission. EVIDENCE: The Registered Nurses from the home visit people who are referred for placement and take with them the homes own service users information sheet/pre-admission assessment form. This is used to assist them in gathering valuable information, to use along side the referring agents information, so that an informed decision can be made about the suitability of proposed placement. The form is very comprehensive covering a wide range of issues that need to be known about an individual such as previous medical history, Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 9 problems with mobility and continence, medication, dietary needs and the names of contacts such as the next of kin and any Social Workers involved with the individual. The inspector saw several completed forms that are held in the nurse’s station until an admission is agreed and occurs. Once an admission takes place the person in charge of the shift told the inspector this valuable information is filed in the administration office inside the home and not with the service users active file. The form is a good format that provides a base level of information on every service user from which to gauge any changes in their condition on. The inspector suggested that it would be beneficial to hold this information with the active file. Down House DS0000030358.V303431.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): The homes performance was assessed against Standards 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are well written but they, and the risk assessments supporting them, are not reviewed regularly enough. Some staff do not respond to the service users call bells in a timely way on some occasions. Medication management and administration is satisfactory. EVIDENCE: Each of the service users have a care plan that is generated from the initial information that is gathered by a Registered Nurse prior to a decision to admit someone to the home. The inspector read three care plans during the tour of the home as they are kept in folders in the service users room. The structure of the care plans is good and the information that supports decisions about how to deliver care is held in the same folder in the form of risk assessments, such as mobility assessments and Waterlow scores. The individual plans covering each subject were well written. However, also in the folder the Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 11 inspector saw a sheet that records the date of a review of each of the sections of the current care plans in use. The three care plans that were read had no evidence to show that they had been reviewed on at least a monthly basis. This had also been observed by health and social care professionals during a recent visit. The body mass index had also been recorded on a monthly basis until April 2006 and then ceased. The person in charge of the shift said that the weighing scales were not easily available for the staff to use. Given the value of this information, particularly where service users had been already assessed as at risk, the practice of assessments and weighing service users should be re-instated at least initially where risks had been identified. During the tour of the home the inspector observed that the home has a variety of pressure relieving aids that are used for the benefit of the service users and are indicated as necessary flowing the tissue viability assessments. The assessments however had not been regularly reviewed. There were also hoists and stand aids available including a electric shower chair that can be tilted and a hoist for use in the bathroom that had a modern disabled bathing facility that has adjustable height. The home has two registered nurses on duty at all times and generally six care staff on during the day, four in the afternoon and evening and two at night for the present population of thirty service users. All the service users are registered with a General Practitioner who will visit the home as required. Service users also attend clinics at the local district general hospital as one service user informed the inspector. The chiropodist and dentist attend the home and make a charge to the service users for their service. The service users were clean and appropriately dressed and reported that the care staff do meet their care needs. The inspector noted that all the service users who were seen in their own rooms had their nurse call bell button beside them. However some service users did say that their call bells were not answered in a timely way and staff would claim to be busy on none care tasks. Care was provided in the privacy of the service users rooms or in other appropriate areas such as the bathrooms. Most of the service users have ensuite or semi-en-suite facilities. There are shared bedrooms and the inspector noticed that privacy screening was provided in these rooms. Medications are stored in locked containers in two areas of the home, both being locked rooms. The medication administration records were looked at by the inspector and found to be satisfactory and there was photographic identification for each service user held with these records. The home has a treatment room and it has recently been refurbished to a good standard. With the completed pre-inspection questionnaire that the home has supplied there was a list of the names of staff that are involved in the administration of medication. The registered nurses are responsible for the administration and management of medication in the home. They have knowledge of the law and the Nursing & Midwifery Council guidance relating to this task. Down House DS0000030358.V303431.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): The homes performance was assessed against Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides appropriate activities for the service users who have a choice to take part in them or not. The food is of good quality and portions and nicely presented. The service users do express their choice in a number of ways such as which entertainment they will take part in and where they will spend their day. EVIDENCE: The home has details of the service users likes and dislikes, food and activities, in their files. The inspector noted that only a small number of the service users use the lounge despite it being homely in appearance. One service user said that she preferred to be in her own room but does go to the lounge for social events. Her room was personalised, as were many others in the home and each of the service users who were spoken to were happy with their own accommodation. The home offers the service users the facility of having their own telephone line and also internet service with broadband connection at a reduced rate from that which the broadband provider charges. The service Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 13 users are given an itemised phone bill that is produced in the home as they have their own server for the telephone system. For those without their own telephone a public phone is available also in the home. The service users have access to a nurse call system in every room in the home including in the lounge and toilets. The two call bells in the lounge did not have cables attached to them at the time of the inspection but do operate from a push button on the face of the mechanism. Service users can have visitors at any reasonable time into the home and they can choose to see them in the communal areas or in their own rooms if they wish. The inspector did not have the opportunity to speak to any of the visitors during this inspection. The home offers a variety of activities for the service users to enjoy such as move to music (therapeutic activity), slide shows and keyboard music. They also provide two coach trips a week during the summer and that has reduced to once a week during the winter. The home has just purchased a new mini bus that will take up to five wheel chairs and has full disabled access. One of the service users commented that she did enjoy the regular coach trips. There is a library service in the home where the inspector saw a variety of books, videos and music compact discs. The local authority will exchange the books on the request of the home. The clients who are able to exercise their choice in many ways such as what food they will eat. The cook asks each of the service users during the afternoon what they would prefer for their meals the following day and makes a record of this. She will also provide an alternative at short notice if a service user changes their mind. The service users each had views on the food they received. Mostly they felt that it was not of the quality that they would have prepared for themselves each having a different lifestyle before moving into the home such as working in hotels and enjoying its cuisine. The inspector saw the main meal that was presented to the service users and thought it looked nutritious, of good portions and nicely presented. Meals can be taken in the lounge or in the service users own rooms. The majority of service users seem to prefer to eat in their own rooms. A large proportion of the service users do require assistance or supervision with their meals and the staff provides this in a dignified way. With the opening of the newly built wing the home will have a new dining room for the service users that has attractive and functional fittings that might attract the service users out of their rooms to make there meals more of a social event. Breakfasts are prepared in the kitchen and then sent to a kitchenette near the lounge for service users who have rooms at that end of the building. Here staff will keep the food hot and prepare fresh drinks and toast to take out to the service users. Drinks and snacks are also prepared in this room during the daytime. Down House DS0000030358.V303431.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): The homes performance was assessed against Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the protection of clients from abuse through training are satisfactory including a clear and accessible complaints procedure. EVIDENCE: The complaints procedure is displayed in several areas about the home and it is well constructed. It informs the reader of the name of the person they may raise a complaint with and the time scale within which they will respond. There is also a copy of the procedure in the Statement of Purpose and an up to date copy of this was given to the inspector during this inspection. Some of the copies of the procedure need up dating as they still give the National Care Standards Commission as the registering authority. The inspector enquired about the issue of adult protection training for staff. The person in charge told him that there is an element of this in the homes induction training and also that they have the Alerter’s Guidance for staff to read. Many of the staff have now attended the one day local authorities Adult Protection training and the remaining staff are waiting dates to attend. The inspector saw evidence in the staff training that verified this information. The homes recruitment procedures are good and help them select only suitable staff to work in the home. Down House DS0000030358.V303431.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): The homes performance was assessed against Standards 19, 21, 23, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good clean accommodation for the service users and a range of aids for the comfort and safety of the service users with disabilities. The lounge is warm and comfortable with a nice outlook but under used by the service users except when there are organised entertainments. The laundry is well equipped and ventilated. EVIDENCE: Down House is located in the mainly residential area of Derriford near the City of Plymouth and close to a major district general hospital. There is a large shopping centre a short drive from the home and a mini market within a garage a short walk away on the level. The home is also on the main bus route Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 16 to the city, which is about 3 miles away. There is parking to the right hand side of the homes long driveway and more will be available when the present building work is completed at the end of this year. The home is made up of a large main house that has been upgraded to provide a number of large bedrooms. A stair lift is used to access the first floor but when the building work is completed there will be a large shaft lift provided that will stop at each floor that the service users accommodate. At this time the home will increase the number of beds it is registered for by eight. It will also have a new high specification kitchen and a new dining room that leads out to the secluded garden area at the side of the home. At present there is only one large lounge in use at the end of the single story extension that leads off from the main house. It is comfortably furnished with a selection of suitable chairs. There is a book case, piano, wide screen television and music centre for entertainment. From this part of the home there are two exits onto a large level patio area that has plants scattered around it and a small raised water feature. Near the lounge there are two toilets and two bathrooms with toilets inside. One bathroom has a new disabled bathing facility that is height adjustable and has its own mobile hoist. The second bathroom is a large wheel in shower room that is equipped with a new battery operated shower chair that has several features for the comfort of the service users. There is also a hairdresser’s sink in this room. The home has a selection of good-sized single and double rooms most of which have en-suite or semi en-suit facilities. The majority of single bedrooms look out onto the patio area. They are well lit by natural light and have good artificial lighting. Radiators are designed so that they do not pose a risk to clients from hot surfaces. All the bedrooms are suitably furnished and personalised by the service users who have chosen to bring in some of their own possessions. Nursing beds, which are height adjustable, are provided along with other nursing aids, such as pressure relief mattresses, where a risk assessment has identified that they are needed. All rooms that are used by the service users have a nurse call system in them. Bedroom doors have self-closures fitted and the lounge has a magnetic self-closure, activated by the fire alarm system, so that the doors can remain open during the daytime. Many of the bedroom doors have locks provided and service users can have there own key if they wish and it is appropriate for them to do so. Some of the bedroom doors are awaiting the arrival of new locks that will be fitted. The home employ there own handy man who keeps the building well maintained being alerted to urgent work by the staff who record items that need attention in a book. Specialist equipment is maintained by competent people under contract. The inspector saw information that provided evidence of this maintenance and was also provided information in the pre-inspection form. The inspector saw a disinfecting sluice that is provided in its own room with hand washing facilities that are to be upgraded. The home has its own laundry that is staffed separately from the home. The laundry is away from any food storage and preparation areas and is well equipped and ventilated. It is equipped with three washing machines that Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 17 have sluicing cycles, two commercial dryers, an ironing press and iron and board, and shelving that has named laundry baskets for each service users. In the “patient information guide” the home asks that clothes are labelled clearly. The main corridor has been provided with a new carpet following comments made in the previous inspection. The home was clean and odour free and is maintained by the housekeeper and her seven staff. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 18 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): The homes performance was assessed against Standards 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ratio of staff to service users in this home is excellent. The level of training given to staff is good. The recruitment procedures are also good and should aid the home in selecting the right staff for the job. EVIDENCE: The home provides nursing care presently to 30 service users who occupy the home. There is a minimum of 2 registered nurses on duty over the 24-hour day. In addition to this they lead a team of 6 care staff during the day and 4 during the afternoon and evening and 2 at night. The duty sheets were seen by the inspector to verify this planning although on occasions sickness at short notice did reduce care staff numbers by one. This is a high ratio of staff and the Registered Individual said that the levels have been set to take into account the needs of the service users and also the design of the building. The person in charge told the inspector that the care staff are allocated to work with groups of service users who occupy sections of the home on a daily basis. There is no key worker system operating at the home although the trained staff are allocated groups of service users for the purposes of updating their care plans. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 19 The inspector spoke to the person in charge of the shift about how new staff are trained. He was told that during the induction period the new staff member shadows a nurse and care staff member learning the skills of care, dignity and respect. They are shown how to handle service users and use equipment. This period extends beyond one week before the new staff member is actually involved in providing any care allowing them time to learn and also to make a decision if this is actually the career that they wish to follow. A new member of staff was also interviewed and she verified that the induction period took several days and prepared her for her duties. She also verified that she had attended fire instruction. Her personal file verified that the induction took place and that before she commenced work the home had received an application form, CV, two written references, personal identity information and a photograph. A Criminal Records Bureau had also been requested with a POVA First request. Three other staff files were read and found to be satisfactory and the inspector provided the Administrator some advice on references from overseas staff employed by the home. The inspector also saw a copy of the individual staff member’s terms and conditions of employment in their files. The home is accredited to carry out adaptation training and has recently had one nurse become successful in completing this training. The inspector noted that in the pre-inspection form 19 service users were identified as having a degree of dementia secondary to their general health problem. They do not present a management problem to the staff. However the staff may better understand their individual needs if the home organised some dementia care training to improve their awareness and approach that should be recorded in the care plans. Another registered nurse was interviewed who provided information about the training that she has received saying that she felt that it was a good level of updating. She felt that the level of staff at the home was good and that in her estimation this was a good home. The Administrator supplies evidence of all the training that the staff have been involved in during the last 18 months. This includes Fire Lectures and Adult Protection training by the local authority. The trained nurses have had refresher training in urinary catheter management and infection control. At present the home employs 25 care staff 8 of which have a National Vocational Qualification at level 2 or above, which is 32 of the care staff. In addition to the 25 care staff the home employs 9 registered nurses, and 18 ancillary staff. The Registered Individual has a daily presence at the home. The Administrator provided evidence that she checks the Nursing & Midwifery Council pin numbers of all nurses employed at the home are up to date. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 20 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): The homes performance was assessed against Standards 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of effective leadership is having a negative effect on the performance of the staff team who are not always meeting the homes objectives. The quality assurance system is not robust enough to have identified this issue earlier. The maintenance, training and administrative tasks are being met to a satisfactory level. EVIDENCE: The home does not have a current Registered Manager. The Registered Individual has provided evidence that he has advertised regularly to recruit one without actual success. Each of the registered nurses are responsible for Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 21 their practice and therefore responsible for the running of the home whilst on duty. Generally the home does run well and achieves its aims and objectives. However, some service users and visitors, including health and social care professionals, to the home have reported areas of dissatisfaction that identify that there are leadership issues that would normally be the responsibility of the Registered Manager. The Registered Individual did accompany the inspector during the majority of the inspection. He did accept the observations of service users and those other that he was made aware of and immediately provided a positive response towards addressing the shortcomings. The home does use service users questionnaires as a quality assurance tool. This is not up to date. Effective quality assurance methods were discussed for the Registered Individual to consider. There is a commitment towards a quality service that can be seen in the investment in the premises, equipment and the staff training. Also the home monitors the policies and procedures and has provided evidence that most of these have been reviewed and updated as necessary during 2006. The home has its own good accounting system and produces clear information about any charges to service users outside of their contracted fee such as for news papers and telephone calls. They do not manage the affairs of any of the service users. The Registered Individual and the Administrator have provided evidence that the home is satisfactorily serviced and equipped to make it safe for the service users and the staff to work in. The staff are also trained to enable them to provide good standards of care, safely to the service users. Where accidents have occurred a record has been made and the inspector sampled the reports during the inspection. The home has maintained its fire prevention training and equipment particularly during the building work that has been carried out to the satisfaction of the Fire Authority. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 22 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 2 8 2 9 3 10 3 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 3 X 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 23 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 2 3 Standard OP7 OP31 OP33 Regulation 15(2)(b) 8(1) 24(1) Timescale for action Service users care plans shall be 14/11/06 kept under review. The home should recruit a 28/02/07 competent person to be Registered Manager. The Registered Individual shall 31/01/07 establish and maintain a system for reviewing and improving the quality of care provided by the home. 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. 1 Refer to Standard OP3 Good Practice Recommendations The initial assessment information should be with the service users active file along with other referral information. The files are presently fragmented about the home. Risk assessments should be carried out including those that identify problems related to nutrition and any problems in doing so should be overcome. The home should maintain its National Vocational DS0000030358.V303431.R01.S.doc Version 5.2 Page 24 2 3 OP3 OP28 Down House 4 OP27 Qualification training of care staff to achieve 50 . The staff should receive some dementia care training to improve their awareness of the condition and needs of the individual service users who suffer from this condition. Down House DS0000030358.V303431.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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