CARE HOMES FOR OLDER PEOPLE
Downham Cottage Downham Cottage 111 Longdown Lane South Epsom Surrey KT17 4JL Lead Inspector
Susan McBriarty Unannounced Inspection 13th October 2005 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 Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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.V258439.R01.S.doc Version 5.0 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 Oaklands 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.V258439.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Of the 8 learning disability persons (LD) accommodated up to 6 may fall within the category LD(E), Learning Disability/Older People The age/age range of the persons to be accommodated will be: Up to 8 over 30 years of age, up to 6 residents 65 years old and over. 4th July 2005 Date of last inspection 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. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second for 2005-2006. The inspector spent 3.5 hours at the home. All the standards were assessed during the inspection of the 4th July 2005. This inspection focussed on the experience of the home by the residents. During the inspection the Inspector observed the residents at various points, spoke to two of the residents and three of the staff members including the manager. The residents finance documents and part of the staff recruitment procedures were sampled by the Inspector. 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. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. Previous requirements had been made regarding the provision of a statement of terms and conditions to each resident. This was achieved in April 2005. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. Observations made during this inspection noted that staff members were respectful to residents and responded quickly and quietly to residents needs as they arose. One specified person was unwell at the time of the inspection and told the Inspector that he was pleased that the house cat wanted to keep them company. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 the following standard(s): 12 EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. The Inspector discussed the social and leisure activities undertaken by the residents. A number of the residents were assessed as requiring additional one to one support at various times during the week. These times were noted clearly within the weekly activity record and the support could be varied according to the needs and preferences of the specified person. On arrival at the home the staff were playing music appropriate to the age group of the residents and were encouraging them to take part in singing along to the music. One specified person was able to indicate their preferences regarding this activity and staff responded appropriately. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 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 the following standard(s): 20 EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. During the inspection of the 13th October the home was seen to be clean and tidy. The Inspector made a tour of the garden area and found the pathway to the rear of the garden to be difficult to negotiate for people who have a mobility problem. A requirement was made that the path be risk assessed and if necessary handrails and improved surface provided. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. During the inspection of the 13th October the Inspector was unable to locate evidence of Criminal Record Bureau (CRB) checks for two staff members. The Inspector had been invited to the check the details held by the home, the CRB records were held in a sealed envelope in a lockable space but not accessible to the manager. In checking the information against the staff files it was not possible to evidence provision of CRB checks for those two specified staff members. The manager assured the Inspector that CRB checks would have been carried out as they were long serving staff members. A requirement was made that the manager seeks confirmation of the CRB’s and place the necessary evidence in the personnel files. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 EVIDENCE: These standards were assessed during the inspection of the 4th July 2005. During the inspection of the 13th October the inspector sampled the financial records of the residents. The cash balance was found to be correct, one query was raised by the Inspector and clarified on the day. The records held were clear and would enable an audit of any expenditure. The organisation provides a monthly statement to the home of the level of savings held by each resident. Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 14 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 2 X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 15 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 20 Regulation 23(2)(o) Requirement The registered person must risk assess the pathway at the rear of the home and provide the CSCI with a timescale of any works required. The registered person must confirm with the CSCI that CRB checks have been received for those specified staff members. Timescale for action 19/11/05 2 29 19(11) 19/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Downham Cottage DS0000013631.V258439.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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