Inspection on 06/09/05 for Down House

This inspection was carried out on 6th September 2005.

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

Down House 13/09/07

Down House 25/10/06

Down House 02/02/06

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 277 Tavistock Road Derriford Plymouth PL6 8AA Lead Inspector Doug Endean Unannounced 6 September 2005 th 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 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 D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Down House Address Down House, 277 Tavistock Road, Derriford, Plymouth, Devon, PL6 8AA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 789393 01752 769747 Mayhaven Healthcare Limited Jacqueline Carol Hunt 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 of places (43), Terminally ill (4) Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users can be admitted over the age of 40 years in relation to the Physically Disabled category. Date of last inspection 22/02/05 Brief Description of the Service: Down House is a Care home which is registered to take 43 Service Users of either gender over the age of 65 who require nursing care, and a maximum of 3 Service Users requiring personal care only. The home is situated in the Derriford area of Plymouth and is on a main bus route to Plymouth city centre. The home is a large adapted older house with a modern, purpose built, single storey extension. The ‘main house’ is on two floors with access via a stair-lift. The home currently has no passenger lift, but plans are being discussed for this to be introduced. There are 4 lounge/ dining rooms, one of which is accessed via 2 steps. The well maintained gardens are extensive and have a mix of shrubbed, paved, gravel areas with attractive pots for plants. In addition to this there are lawn areas. All areas are accessible to Service Users. The Manager/Matron is a level one registered nurse who heads up a team of Nursing, care and ancillary staff. At present there is substantial building work being carried out to extend the home to provide more rooms, a new kitchen and other facilities to enhance the overall service. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, and the first visit of this home by this inspector. The Registered Manager was not on duty at the time of this inspection. The inspector focused on obtaining knowledge of the layout of the home and the facilities it offers now, and intends to offer when the building work that is being carried out, is complete. The Administrator for Down House and also the Administrator for the sister home, St James Lodge assisted in the inspection. The trained nurses also took part in the inspection and answered questions about the home and the way care is provided. The inspector spent approximately two hours and thirty minutes at the home. In this time he toured the home and spoke to one visitor, three clients and seven staff including the two Administrators, laundry lady and Cook. Four staff files were reviewed and evidence of staff training seen. Fire and Accident records were also looked at during the inspection. What the service does well: What has improved since the last inspection? 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. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The inspector did not inspect against these standards on this occasion. EVIDENCE: Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 10 The staff treat the clients with respect and provide care in a way that maintains their dignity. EVIDENCE: The staff were observed by the inspector delivering care in a respectful manner that met with the agreement of the clients and maintained dignity. Personal care was provided in the privacy of the client’s own rooms or in other appropriate places such as the bathroom. There is a public telephone at the main entrance of the home and there are telephone points in all the bedrooms. Visiting can take place either in the privacy of the client’s own room or in the communal areas if the clients wish. The laundry had individual baskets for each client’s personal clothing. Clients provide and wear their own clothing at all times. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 The home encourages contact between the clients, their relatives, friend and the wider community. EVIDENCE: The client’s and their relatives are at liberty to decide if they wish to participate in activities outside the environment of the home and the staff will provide support where this may be needed such as having a client ready to leave the home at a specified hour. Visiting is encouraged, and visitors are welcomed by staff. The one visitor spoken to by the inspector felt very comfortable in the home environment and made very positive remarks about the care his wife had received in the home. Visiting can take place in either a client’s own room or in the communal areas. Information about visiting is available to clients and visitors in the statement of purpose. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. The arrangements for the protection of clients from abuse through training are satisfactory including a clear and accessible complaints procedure. EVIDENCE: The complaints procedure was displayed in a prominent position in the main entrance. It is also available in the statement of purpose and contains information about how anyone can raise a concern or complaint either with the home or with the Commission for Social Care Inspection should they not be satisfied with the homes response. Some of the client’s spoken to by the inspector did know who to speak to if they had a concern or complaint. Not all the client’s spoken to were able to make reasonable comment on some subjects. The home records any issue raised and how they have been addressed. The inspector has noted that there has been no complaints raised with the Commission or recorded in the last two inspection reports that go back to July 2004. The inspector did see evidence of Adult Abuse training being provided to the staff of the home by Plymouth City Council Adult Protection Team. There were also copies of the Plymouth City Council/National Health Services Alerters Guide and Handbook. In addition to the this staff have also attended Elder Abuse Training and evidence of this was seen in the samples of staff files that were looked at by the inspector. The home does have a whistle blowing policy. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The home is in good order providing clean, comfortable and well-decorated accommodation for the clients who live there and the housekeeping arrangements are good. EVIDENCE: The home is located in the Derriford area of Plymouth off the road on the bus route to the city. During his tour of the home the inspector noted that despite the building work that is underway the areas used by the clients were clean and in good order. However the carpet in the corridor that has bedrooms off it needed attention, as it was not lying level along its length. The grounds in front of the bedrooms were laid to lawn that is being cared for and provides a level area with good access to clients if they wish to use it. The building work may however make it less desirable at the time of the inspection. There were no offensive odours anywhere in the home. The clients have the option of purchasing “Dorgards” that will allow the door to their bedroom to remain open and meet with the local Fire Authority requirements. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 12 The home has its own laundry that was well laid out and equipped. The wall and floor surfaces are easily cleaned and the floor covering is impermeable to water. The washing machines have a sluicing cycle and there are policies and procedures that cover the issue of infection control. The clients have their laundry placed in baskets with their names on that is then taken to their own room when cleaned and ironed. The laundry is sited in an area well away from the kitchen and storage of any foodstuffs and laundry does not pass through the kitchen on its way to the laundry. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, & 29. The number and skill mix of staff on duty at the home is satisfactory and the homes recruitment procedure is good. However, when recruiting staff from overseas the procedure needs to be improved. EVIDENCE: During the time of the inspection there was 40 clients resident at the home. The level of staffing and the skill mix was felt by the inspector to be satisfactory. The duty rota provided evidence that two registered nurses are on duty at all times over the 24 hour day and they are supported by adequate numbers of care staff who have been trained to meet the care needs of the clients. Evidence was seen in the staff files that showed staff have completed such training as manual handling, infection control, and Elder Abuse. In addition to this care staff have completed at least an NVQ in care at level 2. Evidence of these qualifications was seen in the files that were randomly sampled by the inspector. There are separate staffing arrangements for the laundry, catering and domestic duties at the home. The home also employs its own Administrator. The staff files were well constructed and held such information as proof of identity, references and Criminal Records Bureau checks. However the home does employ staff from overseas and there was no evidence of police checks from their country of origin in the files. The Administrator told the inspector that all staff are given a copy of the code of conduct and practice produced by the General Social Care Council. There were copies of this booklet in the Administrator’s office to support this statement. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 14 Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The inspector did not fully inspect these standards on this occasion. EVIDENCE: Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 17 YES Are there any outstanding requirements from the last inspection? 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 29 Regulation 19 and Schedule 2 Requirement The Registered Person should ensure that each member of staff the result of a current police check when recruited to the home from overseas. Timescale for action 30/11/05 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 19 Good Practice Recommendations The carpet in the main corridor by clients rooms needs attention to remove any trip hazard. Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Down House D52-D04 S30358 Down House V233027 060905 Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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