Inspection on 21/04/05 for Downhurst

This inspection was carried out on 21st April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Downhurst 06/09/07

Downhurst 22/09/06

Downhurst 31/10/05

Downhurst 16/08/04

Downhurst 05/05/04

Downhurst 18/11/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Downhurst 76 Castlebar Road Ealing London W5 2DD Lead Inspector Susheila Ramcharran Unannounced 21st April 2005 at 9.45 am 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. Downhurst Version 1.10 Page 3 SERVICE INFORMATION Name of service Downhurst Address 76 Castlebar Road, Ealing, London, W5 2DD 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) 0208 997 8421 0208 810 9044 Ealing Eventide Homes Ltd Ms Malgorzata Guillen Care Home 26 Category(ies) of PD(E) Physical disability over 65 and OP Old age registration, with number (26) of places Downhurst Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: A variation was granted for five named service users with dementia. Date of last inspection 16/8/04 Brief Description of the Service: Downhurst is a home for older people located on a busy road within walking distance of Ealing Broadway. There are buses to Ealing and Greenford, passing by the home, and the tube and mainline stations at Ealing Broadway and West Ealing are within easy access. The home was opened in 1948 and consists of a large, detached period three-storey house with an extension, built in 1951, to the rear of the building. The two buildings are joined by an interior walkway. The home is registered for twenty six service users and its categories of registration are old age and physical disabilities. However, not all areas of the home are suitable for people with poor mobility. There is accommodation for 25 service users in single rooms. The double room is currently used as a single room. There are four bathrooms and eight toilets. The home has three lounges, a separate dining room and other spaces which can be used as quiet areas. There are very well-maintained and pleasant gardens around the home with areas of seating. There are several offices located throughout the building.Downhurst is owned and managed by Ealing Eventide Homes Limited, a not-for-profit organisation. There is a Board of Management. The home has a Registered Manager, Deputy Manager, a staff team of senior, day and night Support Workers. There is an administrator, a handyperson, gardener, two cooks, kitchen, laundry and domestic workers Downhurst Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between the hours of 9.45am and 5.15pm on the 21st April 2005. The Registered Manager was present. There were twenty-one service users, one of whom was in hospital, and four vacancies. There were positive interaction between the staff and service users. The atmosphere was pleasant and relaxed. Service users reported that staff treated them with respect. There are seven requirements made at this inspection, five of which are restated from the previous inspection. Some of these relate to ensure that all of the staff team receive updated training in basic courses. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Downhurst Version 1.10 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 Downhurst Version 1.10 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) 1, 3, 4 Service users are provided with the information they need about the home to be able make a choice as to whether they would like to live there. There are procedures in place to ensure that proper assessments take place prior to service users moving into the home. Service users are written to once the home is satisfied that the required care can be provided. This gives reassurance to the service users and their representatives that their care needs would be met. EVIDENCE: The Statement of Purpose has been updated and a copy provided to the Commission for Social Care Inspection as required. Two of the records examined for newly admitted service users had the required pre-assessments documentation and confirmation that the home can meet their needs. One service user spoken to confirmed that the staff are aware of her/his needs. The home had been, at the last inspection, required to consider its options with regards to caring for the service users living in the home who had a diagnosis Downhurst Version 1.10 Page 8 of dementia. The Commission for Social Care Inspection granted a variation for six such named service users. At the time of the inspection visit, five of the six service users were still in the home. Downhurst Version 1.10 Page 9 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) 7, 8, 9 The health and personal care needs of the service users are identified and generally met. There has been a shortfall in ensuring that risks assessments are in place for all the service users and signing for medication administered. This has the potential to place the service users’ health and safety at risk. EVIDENCE: Each service user has a care plan, which is now signed by them, or their representatives as appropriate. A previous requirement was made in respect of risk assessments being in place for all activities undertaken by the service users. The records of one service user, who was admitted, following a stroke, did not contain a risk assessment. Risk assessments and reviews of the care plans, including the risk assessments, were seen in two other care plans examined. Following a requirement at the previous inspection for risk assessments to be updated, to include the risks of the stairs, the Registered Manager stated that this had been done. In addition, there are monitoring forms which are completed following accidents to service users and these were seen at the time of the inspection visit. Downhurst Version 1.10 Page 10 Two requirements were made in respect of medication administration at the previous inspection visit. Monitoring sheets of non-signing of medication are kept. Discussions took place with the Registered Manager on the importance of taking further action, other than bringing this to the attention of the staff concerned. This should include retraining. The weekly dossett system is used. Medication required for cold storage is kept in a locked tin in the refrigerator. Downhurst Version 1.10 Page 11 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) 12, 15 Arrangements are in place to meet the social, religious and dietary needs of the service users. Individual and group activities are on offer most days of the week by a paid activities coordinator or a member of the Trustees of the home, which provides variation and interest for the service users. Choices and flexibility are available at meal times. EVIDENCE: Several service users spoken to commented that they are encouraged to participate in activities of their choice regularly. One service user said that she/he has a number of visitors during the day, has a television and videos to look at, has visits from the priest, tidies the bedroom and did not wish to participate in social activities. The staff respect this person’s wishes. Individual activities were in progress during the inspection. Two service users said that they could go to church but preferred to have Holy Communion at the home. A sample of the records seen indicated that service users’ religious wishes are noted and attempts made to meet these. The menu seen offered choices at meal times for the service users. The lunchtime meal on the day of the visit was roast chicken legs, cottage pie, mixed vegetable, creamed potatoes, bakewell tarts and custard, fresh fruits were also available. The evening meal was soup, salad, sandwiches and freshly baked scones with cream. There are two Polish service users and a suggestion was made for enquiries as to whether they would sometimes like to have a a Downhurst Version 1.10 Page 12 traditional Polish meal. The service users said that they were satisfied with the meals provided. Service users commented positively about the meals provided and that they have the choice where to have their meals. Downhurst Version 1.10 Page 13 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 service users were aware of the complaints procedures and were confident that their concerns would be listened to and taken seriously. Adult protection procedures are in place and staff training is being undertaken in order for staff to be aware abuse issues and offer protection to the service users. EVIDENCE: The home has a complaints policy and procedure, which is displayed for service users and visitors to have access to complain if they so wish. A suggestion file is kept by the visitors’ signing in book for comments/suggestions to be made. No complaints were made to the Commission for Social Care Inspection since the previous inspection visit. There was one complaint from a professional worker about a staffing issue and the Registered Manager appropriately investigated this. A previous requirement was made in respect of the Registered Manager to make arrangements for all staff to undertake training in the Protection of Vulnerable Adults from abuse. The training file seen indicated that twelve staff have so far participated in such training and there are plans for the remaining staff to undertake this. This was a requirement at the last inspection and is repeated. Downhurst Version 1.10 Page 14 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, 20, 25, 26 The home generally provides a pleasant living environment. The garden is maintained to a high standard with seating for the service users. This is a very attractive facility for the service users. The areas that have steps and stairs and no lift, are not suitable for people with poor mobility. There are plans to address this in the future. EVIDENCE: Some redecorating was being undertaken at the time of the inspection. The lounges and seating areas are well furnished and comfortable. The adjoining corridor has seating for a few service users, which was being used at the time of the visit. This area overlooks the garden. The garden is maintained to a high standard and is very attractive. The service users spoken to stated they enjoy being in the garden especially in the good weather. There are areas of the home, which require updating, particularly those that are not suitable for service users with mobility problems. The chairman of the Trustees stated that there are plans to address this in the future. Downhurst Version 1.10 Page 15 To minimise the risk to service users, it was required that the radiators in the home were covered for safety. This work has now been completed. The training of staff in infection control was also required to be undertaken and the records indicated that ten staff have now attended this course. The remaining staff will be required to be attend this training. Downhurst Version 1.10 Page 16 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, 30 Although there is an emphasis on training in the home, not all of the staff have undertaken all of the basic courses, for example, first aid and moving and handling. As the home has a dementia category, it needs to be demonstrated that staff are sufficiently trained to provide appropriate care. Enough staff should be employed to ensure that excessive hours are not worked by the staff team. EVIDENCE: It was a previous requirement that sufficient staff must be employed to cover the rota, holidays and training. There has been no increase in the hours provided. The Registered Manager, in her response to this inspection, stated that staff are willing to work extra hours to cover vacancies and absences. The home needs to keep this under review to ensure that there are no health and safety issues arising from staff working long hours to the detriment of the service users. The Registered Manager stated that recruitment forms have been amended, with additional information gathered, to help to safeguard the service users. This was required at the last inspection. A staff member was positive about the training that is available in the home. However, a training skills analysis showed that a number of staff have not completed all of the basic training courses. Eight of the staff have had dementia training. This should be extended to all of the staff as the home has had, since the last inspection, a variation for six people with dementia to remain in the home. All of the basic training courses need to be undertaken Downhurst Version 1.10 Page 17 by all of the staff, including first aid and moving and handling. It needs to be demonstrated that that staff have the knowledge and skills to meet their needs. Five of the staff have undertaken their NVQ Level 2 qualification and five more staff are in the process of taking NVQ Level 2 or 3. Downhurst Version 1.10 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31, 33, 34, 37, 38 There was evidence that the management of the home provides leadership and guidance to maintain a good quality of care to the service users. Work is being undertaken on quality assurance. EVIDENCE: The Registered Manager is undertaking her Registered Managers Award which was postponed due to circumstances beyond her control. She has now recommenced this. She is an NVQ Assessor. She will be required to undertaken a care qualification in due course. A previous requirement on quality monitoring has resulted in questionnaires being sent to service users, visitors and professionals. These have not yet been analysed. When completed, the summary needs to be submitted to the Commission for Social Care Inspection and service users. Members of the Trustees Committee make regular visits to the home, as required by Regulation 26, and these reports are generally detailed and informative. Downhurst Version 1.10 Page 19 The Chairman of the Trustees gave information on the financial viability of the home. He said that the Registered Manager has the authority to purchase items which are required within an agreed budget. The records examined on this inspection, included a sample of care plans, risk assessments, medication, fire, training and staff roster, were found maintained and stored in reasonable order. In response to a requirement at the previous inspection, the London Fire & Emergency Planning Authority had visited the home in February 2005. The requirement regarding the fastening on the front door was met. Fire drills are taking place as required and fire points are tested. The Environmental Health Officer had visited the home in January 2005 and the requirements made had been met. Downhurst Version 1.10 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x x 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 3 x x 3 3 Downhurst Version 1.10 Page 21 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 7 Regulation 13 (4) c Requirement Risk assessments must be in place for all service users in respect of their health needs. (Timescale of 30/9/04) not met) Appropriate action must be taken when medication errors are made with the staff members concerned. (Timescale of 31/8/04) not met) The Registered Manager must make arrangements, by trainining or other measures, to prevent service users being harmed or suffering abuse. (Previous timescale of 31/10/04 not met) Training in infection control must be in place for all staff including the laundry and cleaning staff. (Previous timescale of 31/10/04 not met) Sufficient staff must be employed to meet the needs of the service users. (Previous timescale of 31/10/04) not met) Dementia training must be extended to all staff to ensure the specialist needs of the servcie users. All basic training courses must be undertaken by all of the staff Version 1.10 Timescale for action 30/6/05 2. 9 13 (2) 17 (1) (a) Schedule 3 (i) 13 (6) 30/6/05 3. 18 31/7/05 4. 26 13 (3) 31/7/05 5. 27 18 (1) (a) 31/7/05 6. 30 18 (1) c (i) 18 (1) c (i) 31/7/05 7. 30 31/7/05 Downhurst Page 22 team. 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 Good Practice Recommendations Downhurst Version 1.10 Page 23 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Downhurst Version 1.10 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!