Inspection on 01/12/05 for Downham Cottage

This inspection was carried out on 1st December 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 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

Downham Cottage 13/10/05

Downham Cottage 31/08/04

Downham Cottage 28/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Downham Cottage Downham Cottage 111 Longdown Lane South Epsom Surrey KT17 4JL Lead Inspector Mary Williamson Key Unannounced Inspection 1st December 2006 10:00 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 Downham Cottage DS0000013631.V322493.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. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downham Cottage Address Downham Cottage 111 Longdown Lane South Epsom Surrey KT17 4JL 01372 206230 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) Surrey and Borders Partnership NHS Trust Miss Lisa Moody Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (6) of places Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Downham Cottage is a large detached building situated on the borders of Epsom Downs. The home is registered to accommodate eight service users with a learning disability. The service users are all provided with a single bedroom. The lounge and dining rooms are shared communal areas of the home and are easily accessible, spacious and comfortably furnished. The premises have a large garden at the rear of the building and off street parking to the front of the building. The fees charged range from £39,918 to £89,083 per year. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was undertaken by Mary Williamson who is a Regulation Inspector. Miss Lisa Moody the Register Manager was present throughout the inspection. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. Currently there are seven service users living in the home. It was possible to meet with five service users and talk to them with the support of staff and the use of gestures. It was also possible to meet with staff throughout the inspection. The inspector would like to thank the service users, manager and the staff on duty for their hospitality and help during the inspection process. What the service does well: What has improved since the last inspection? Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 6 There were two requirements from the last inspection both of which have been met. The pathway at the rear of the home has now been made safe. The outstanding CRB (Criminal Records Bureau) disclosures are now in place. 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. Downham Cottage DS0000013631.V322493.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 Downham Cottage DS0000013631.V322493.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): 1, 2, 3, and 5. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users have a service user guide and contract of occupancy in place. They also have a pre admission needs assessment and a contract on file. EVIDENCE: The service users have a copy of the service users guide and statement of purpose in their room, which is also available in symbol format if required. The current service users have a needs assessment in place. Assessments were seen for AC, CL, and DF. The Trust has updated a basic pre admission needs assessment format and the manager stated that she would use this for future admissions to the home. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 9 Contracts of occupancy are in place and have been signed by the manager and the finance director on behalf of the service users. Trail visits are offered to prospective service users. These are staggered and range from a short visit for coffee to an overnight stay, to a weekend visit. These visits are also used as part of the pre admission needs assessment. Downham Cottage DS0000013631.V322493.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, 10, and11. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users health and medication needs are met with dignity, as outlined in well- documented care plans. EVIDENCE: Individual care plans are in place. Care plans were seen for AC, CL, and DF. These are well written with input from the service user whenever possible. The information gathered at the pre admission needs assessment, observation during trial visits, and other relevant reports also form the basis of the care plan. These are reviewed and updated at regular intervals. Risk assessments and health action plans are also included in the care plans. The arrangements in place to meet the service users health needs are satisfactory. All the service users are registered with a local GP and are well supported by him. There is also good support from the district nurses who visit Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 11 the home on request and will undertake tasks to include dressings and administer flu vaccines. The chiropodist visits the home regularly and dental treatment can be accessed at Bourne Hall dental clinic. The Royal Association for the Deaf will undertake hearing tests and Physiotherapy can be arranged on request. The manager stated that the service users can visit the local optician or home visits can be arranged. There is a policy in place for the administration of medication. All the staff in the home who administers medication are familiar with this policy. Medication is supplied by Lloyds Pharmacy who also undertake medication audits. The Trust provides training in the safe administration of medicines. The medication recording charts were seen and are well maintained. Currently there are no service users in the home who self medicate. Staff were observed to interact with service users in a respectful manner. They attend to service users needs with dignity and privacy. There is a bereavement policy in place and the manager explained that a longstanding service user passed away since the last inspection and the home was able to care for him with the support of the GP and the District Nurses. Downham Cottage DS0000013631.V322493.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, and 15. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The leisure activity programme in place meets the individual and collective needs of the service users. Catering arrangements provide service users with a balanced and wholesome diet. EVIDENCE: Each service user has an individual leisure and social activities programme in place. Activities include access to day centres, hydrotherapy, trips to the theatre, cinema, eating out, and shopping. There is additional funding provided by social services to provide one to one activities for service users either in the home or to access community activities. Two students from Epsom College also visit the home and befriend the service users as a yearly project. Holidays are provided but some service users prefer to have special days out or long weekends away. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 13 Staff support service users to maintain family and friendship links whenever possible. Visitors are welcome in the home at any reasonable time. The catering arrangements in the home are satisfactory. The manager stated that she plans the menus with the help of staff and the input of the service users whenever possible. The menus are well balanced and varied. The main meal is cooked by the staff and served in the evening. AC stated that the food was very good, D also made positive gestures when asked about the food. The manager stated that there is access to a dietician for support and advice if required. Downham Cottage DS0000013631.V322493.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. The complaints and abuse awareness policies and procedures protect the service users living in the home. EVIDENCE: The complaints procedure is also included in the service users guide, a copy of which is kept in individual service users rooms. Due to capacity service users would need considerable support to make a complaint. Staff are aware of this procedure and felt confident to use this on behalf of the service users. There was one anonymous complaint since the last inspection, which has been resolved. The home has an abuse awareness policy in place and staff confirmed that they had received training in this during induction training. There is also a copy of Surrey’s Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place and all senior staff have attended training in these procedures. There is a local authority poster placed by the telephone in the office with an emergency telephone number for staff to use if this policy has to be implemented. Downham Cottage DS0000013631.V322493.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, 20, 21, 24, and 26. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users have access to safe, comfortable and well -maintained individual and communal facilities, which are clean and odour free. EVIDENCE: The location and the layout of the home is suitable for its stated purpose. It is accessible, safe, and meets the service users individual and collective needs. The home was clean and tidy. There is a well-furnished lounge and dining room, which provides a homely atmosphere, and service users were observed to be relaxed in this environment. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 16 All bedrooms are single occupancy and these have been personalised to reflect individual personalities and hobbies. Key workers help service users maintain their personal space. There are ample bathrooms and toilets situated throughout the home and these have been adapted to meet the mobility needs of the service users. The kitchen is domestic in appearance and is well equipped to meet the catering need of the home. Service users require help and support to access the kitchen facilities. Downham Cottage DS0000013631.V322493.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 (adequate). This judgement has been made using available evidence including a visit to this service. A competent and trained staff team meets Service users needs. The recruitment procedure in place does not protect the service users. EVIDENCE: The staff duty rota was seen and the number and skill mix of staff of the staff on duty was sufficient to meet the assessed needs of the current service users. There was three staff on duty for the am shift, and three for the pm shift. Two staff are on duty during the night. All the staff confirmed that they have a job description and a contract of employment. All new staff undertake induction training. There are currently six staff employed in the home with an NVQ level 2 in care. There is a record of staff training in the home, which outlines all training undertaken and the dates this training is required to be updated. The recruitment policy operated by The Trust is usually robust and protects service users. However shortfalls were observed during this inspection. Employment records were seen for FN, and LW. Both files did not contain an Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 18 application form and written references. The manager sated that these are retained in the Trust’s main office. A requirement has been made accordingly. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 19 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, 32, 33, 36, and 38. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of the service users, which promotes the health and welfare of the service users who live there and the staff who work there. EVIDENCE: The home is well managed by a competent manager who has worked in the home for nine years. She is a qualified nurse with an RMNH qualification. She is also undertaking her RMA (Registered Managers Award). She is supported by a deputy manager, seven senior care support workers, and four support workers. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 20 The staff team confirmed that the management approach in the home was open and transparent and an open door policy was in operation. The manager undertakes formal staff supervision every six weeks and this is recorded and retained on file. She is also undertaking NHS Knowledge and Skills Framework interviews, which is mandatory for all staff. Quality assurance is monitored by Regulation 26 visits which are sent to The Commission for Social Care Inspection, yearly audits, and feedback forms. There is a wide range of health and safety policies and procedures in place and a selection of these were sampled throughout the inspection. Risk assessments are in place for all identified risks. Fire safety records are maintained and contracts are in place for the maintenance of fire fighting equipment and emergency lighting. Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19(4)(b) Requirement The registered person shall not allow persons to work in a care home unless all the required documentation listed in Schedule 2 is in place. This must include two written references and a completed application form. Timescale for action 12/01/07 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 Standard Good Practice Recommendations Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Downham Cottage DS0000013631.V322493.R01.S.doc Version 5.2 Page 24 - 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. 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