Inspection on 22/09/06 for Downhurst

This inspection was carried out on 22nd September 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

Downhurst 06/09/07

Downhurst 31/10/05

Downhurst 21/04/05

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 Ms Susan Woolnough-Singh Unannounced Inspection 22nd September 2006 11:00 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 Downhurst DS0000027702.V307267.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. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downhurst Address 76 Castlebar Road Ealing London W5 2DD 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) 0208 997 8421 0208 810 9044 Ealing Eventide Homes Limited Ms Malgorzata Guillen Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five named service users, can continue to be accommodated under the category of Dementia, as agreed by the Commission For Social Care Inspection on the 12th November 2004, whilst the home can meet the needs of all service users. The home must advise the CSCI when a service user no longer resides at the home. 31st October 2005 Date of last inspection 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 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 and a staff team of senior, and day and night Support Workers. There is an administrator, a handy person, a gardener, two cooks, a kitchen assistant and laundry and domestic workers. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Downhurst Care Home. All of the Key standards for older people were assessed on this occasion. The inspection took place between 11am and 4.30 pm. The Inspector met with the Deputy Manager who assisted with the inspection process; the Registered Manager was not on the premises at the time of the inspection. The Inspector spoke with three service users about their experience of the home and also spoke with a regular visitor to the home. A tour of the building took place; records relating to service users, staff and health and safety were examined. There were two vacancies for service users at the time of 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. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 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 Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 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): 1,3 and 6 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive information about the home prior to admission. An assessment of need is completed to ensure the correct placement is made. EVIDENCE: A Service Users Guide is available a copy of which is kept in service users bedrooms. Assessments of service users needs takes place prior to admission to the home, the placing Local Authority usually completes these. The inspector looked at four assessment forms. Downhurst Care Home does not offer Intermediate Care. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 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): 7, 8, 9, and 10 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s health and personal care needs are set out in a plan of care. Health care needs are identified as part of the care plan. A system is in place for the safe administration of medication. Observation and discussion with service users and a visitor to the home indicated that service users are treated with dignity. EVIDENCE: A plan of care is available for each service user. The Inspector looked at four of these. The Care Plans are comprehensive and cover general information: a daily living and needs assessment and a plan of care and review procedures. The care plan covers personal care, physical well being and daily living and social activities. The Inspector noted that care plans are reviewed monthly. Service users health care needs are incorporated into the care plan. The plan covers medical history, medication and mental health and cognition. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 9 Service users are registered with local General Practitioners. Service users confirmed that they had assistance with their health needs. A medication policy is in place. Medication is administered from a dosset box system, which is prepared by a local Pharmacist. There is a method for checking in medication and ensuring that medication has been correctly administered. The Deputy Manager carries this out. The majority of care staff have attended medication training, the Deputy Manager gives in-house training, and staff are observed and shadowed with regard to their administration techniques. At the time of the inspection all service users had single rooms. The Inspector spoke with service users about their experience in the home in relation to privacy and dignity. Service users indicated that they were comfortable with the personal care given by staff and that staff are available to help as necessary. A regular visitor to the home was interviewed by the Inspector, he/she said the home was cheerful and the staff courteous. Staff were observed to be working with service users in a calm and respectful manner. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 10 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): 12,13,14, and 15 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users appeared to be satisfied with the care offered in the home. Activities are arranged for service users and residents meetings take place. Service users are encouraged to exercise some choice over their daily routines. Service users are offered a satisfactory menu and a choice of main meals. EVIDENCE: Service users spoken with said that activities such as bingo, quizzes and cards took place, also that weekly exercise sessions take place. Two outings had been made to a neighbouring care home for a barbecue and karaoke night. A priest visits on a regular basis to give Holy Communion. The Deputy Manager confirmed that this was the main religious denomination of service users at Downhurst. Service users indicated that they could follow their own routines, although one service user commented that this is not entirely possible when living in a care home. One service user commented that Downburst is a big home and there is the freedom to go where he/she likes. Service users said they attended meetings with the management of the home. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 11 Two cooks and a kitchen assist are employed at the home. A copy of the menu was given to the Inspector; this looked varied with the majority of dishes being Traditional British. An alternative to the main meal of the day was available. Service users confirmed that they could request drinks at any time and that food can be served in the bedroom if requested. The Inspector had a sample of lunch this was judged to be satisfactory. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 12 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): 16 and 18 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure and Whistle Blowing Procedure. Staff have received training to make them aware of the issues relating to the protection of service users. EVIDENCE: A complaints procedure is available for service users and complaints management is also covered in the staff induction and staff handbook. A Whistle Blowing Policy for staff was also available. Service users although not familiar with the complaints procedure said they would talk to the Manager or Deputy Manager if they had any concerns. The complaints logbook was examined; no new complaints had been entered since the last inspection. One service user said that Downhurst Committee members visit occasionally and ask if residents are satisfied. Resident meetings also take place were service users are asked for their opinions and ideas. The Deputy Manager confirmed that the Placing Authority Protection of Vulnerable Adults procedures are available at the home. The Downhurst Training Skills Analysis provided to the Inspector indicated that the majority of care staff had received Abuse/POVA training. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 13 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): 19 and 26 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with an attractive, spacious and homely place to live. Some improvements could be made to the bedrooms on the lower ground floor of the extension; this would enhance the quality of life for some service users. EVIDENCE: A tour of the building took place. The home is generally well maintained and the standard of cleanliness was good. The home is encompassed by welltended grounds these being a main asset of the home. There is ample communal space and seating areas in the home for the use of service users. The home is divided in two with the original house and an extension to the rear. The main building and the extension are joined by an attractive indoor walkway, which serves as an additional sitting area for service users. The Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 14 original building has some character features such as a wooden staircase and some of the bedrooms on the first floor are extremely spacious and are used as bed/sitting rooms. The extension is of a more modern design. The Inspector was of the opinion that there was some disparity between the bedrooms in the original building and the extension. This was discussed briefly with the Deputy Manager who said a decorating programme was in place. The bedrooms in the extension although adequately furnished and clean did look quite faded and in need of redecoration. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 15 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): 27,28,29 and 30 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate number of experienced staff are on duty to meet the needs of the service users. Care Staff are offered the opportunity to undertake NVQ training in care to further their competence and understanding in this field. A range of training is available for the development of staff. The home needs to ensure that all staff has received the relevant training in health and safety. Satisfactory recruitment practices are in place for the protection of service users. EVIDENCE: The staff team consists of the Registered Manager, Deputy Manager, five senior carers and seven care assistants. The home also employs a full time handyman a gardener, two cooks, a kitchen assistant, laundry person and accounts person. The Downburst Committee comprises of a Chairperson and five Directors with different functions. The files of two new members of staff were examined; the relevant documentation for checking the suitability of candidates was in place. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 16 At the time of the Inspection there were twenty-four service users with two vacancies. Four staff are on duty during the morning/afternoon shift and the same for the afternoon/evening shift, one senior carer is included in this. The Registered Manager and Deputy Manager also work day shifts during the week and some weekends. A requirement was made at the last inspection for staff to be increased at peak times of the day. At the time of the inspection there was one member of staff to six service users, which appeared to be sufficient to meet the needs of the service users. Staff are offered a wide range of training opportunities, these include basic training courses in relation to safe working practice, and the care of older people. The majority of care staff had undertaken training in dementia. The training matrix provided by the home demonstrated that staff are being provided with the relevant training. However, there are some training gaps for some carers in working safely training such as moving and handling and infection control; these need to be addressed. Four staff have NVQ Level 2 and two have NVQ Level 3. Three staff have commenced with their NVQ training. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 17 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): 31, 33, 35 and 38 The Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the experience and qualifications to manage the home in a competent manner. An annual quality assurance is not in place to measure the homes success in meeting its aims and objectives. Health and safety and service user finance procedures are in place for the protection of service users. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 18 EVIDENCE: The Manager has completed the Registered Manager’s Award. She is has a City and Guilds management qualification and NVQ assessors award. Regular meeting for service users take place, the minutes of the last meeting were seen, the agenda covered food, outings, the fire procedure and the heating in the home. An NVQ assessor attended the meeting. An informative newsletter is sent to service users and relatives. A quality survey questionnaire for service users is in place for service users and relatives. The Quality Assurance System for the home needs to be improved. This needs to incorporate an internal audit of the standards in the home. Written records for the transactions of service users money are kept; the Inspector sampled a small number of these. Generally the home handles personal allowance for every day requisites. The service user’s finance policy is available in the service user’s guide. There are systems in place for the health and safety of service users and staff. Risk assessments have been completed for service users on moving and handling, bedroom and personal safety. Staff receive a handbook when they join the service this contains information on safe working practice. The majority of staff have received training in basic health and safety. A health and safety inspection report form is used to check health and safety in the home at regular intervals. The form is comprehensive and covers all the necessary areas of health and safety to be monitored. An Inspection from the Environmental Health Department had taken place in January 2006. Regular fire drills involving all staff had taken place a record of drills was seen. Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 19 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 20 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. Standard OP26 Regulation 23 (1) (a) Requirement An Action Plan of planned decoration and improvement work must be forwarded to the Inspector. A plan must be put in place to ensure all staff must receive training in working safely. Moving and Handling, Infection Control and Food Hygiene. A system must be put in place for reviewing the quality of care in the home and supplying the Commission with a report in respect of this. Timescale for action 01/02/07 2. OP30 18 (1) (a) 01/12/06 3. OP33 24 10/04/07 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 Downhurst DS0000027702.V307267.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 DS0000027702.V307267.R01.S.doc Version 5.2 Page 22 - 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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