Inspection on 31/10/05 for Downhurst

This inspection was carried out on 31st October 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

Downhurst 06/09/07

Downhurst 22/09/06

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 Jean Bovell Unannounced Inspection 11:05 31 October 2005 st 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.V254921.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. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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.V254921.R01.S.doc Version 5.0 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. 21st April 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.V254921.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on between 11.05 am and 4.05 pm on Monday 31st October 2005. The Registered Manager, Deputy Manager, two Senior Care Support Workers, Two Care Support Workers and 22 service users were present. The Inspector spoke to two care support workers, one senior support worker and 10 service users. Records, policies and procedures were viewed. A tour of the building was undertaken and observations were made. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. What the service does well: The home has maintained a permanent staff group of many years. This has benefited the service users by enabling the development and continuity of good working relationships, particularly between service users and their key workers. Members of the care support staff group who spoke to the Inspector expressed satisfaction with the support they received from the Registered Manager and also from within the staff team. They were observed to respond competently to the needs of the service users. The service users were well groomed, appropriately dressed and appeared content and comfortable within their environment. The Inspector spoke to ten service users. They reported being happily settled at the home and commented positively about the care support staff and also the Registered Manager. Service users were observed to interact with their carers in a friendly and spontaneous manner. All health and safety records viewed were satisfactory and indicated that the best interests of the service users were being protected. The home was well maintained and there was a friendly, caring and homely atmosphere. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 6 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.V254921.R01.S.doc Version 5.0 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 Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. The key standards were examined at the last inspection. The home has a satisfactory contract/statement of terms in place which service users or their representatives are required to sign at the point of admission. Relatives and/or friends are invited to view the home prior to the admission of new service users. EVIDENCE: It was indicated on records viewed, that new service users or their representatives were required to sign the home’s contract/statement of terms of conditions at the point of admission. The Registered Manager confirmed that interested relatives and friends were invited to the home and were involved in determining the home’s capacity to meet the separate needs of the service users. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 the following standard(s): 9,10 and 11. The key standards were examined at the last inspection. The home’s policies and procedures relating to medication and also to death and dying were satisfactory. The privacy and dignity of the service users are being upheld at the home. EVIDENCE: The home’s policy and procedures in relation to medication were in place and the records confirmed that medication training had been delivered to the care support staff team. The storage and administration of medication kept at the home were seen to be satisfactory. The Inspector was advised that none of the service users were self-administrating their medication. The service users occupy single bedrooms and all contain separate locks. Staff members were observed knocking on bedroom doors prior to entering and interacting with service users in a respectful manner. Staff members confirmed that assistance with personal care was carried in the privacy of bedrooms or Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 10 bathrooms. Service users who spoke to the Inspector indicated that their privacy and dignity were respected at the home. The home’s policy and procedures relating death and dying were comprehensive and incorporated different cultural and religious needs, practices and expectations. It was indicated on individual service users records that personal wishes or requests were determined during the initial assessment process. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 the following standard(s): 13 and 14. The key standards were examined at the last inspection. Service users are able to exercise choice and control in relation to their daily living routines and contact with family and friends is encouraged and facilitated. EVIDENCE: The home operates an open visiting policy and it was reflected on individual care plans seen that contact between service users and their relatives and/or friends was encouraged and facilitated. The Inspector was informed that several service users attended Sunday Service at their local church, went shopping, had meals out or visited social clubs. One service user went shopping and another was seen returning to the home following a trip to the local community, at the time of the inspection. The Registered Manager confirmed that service users received choice regarding activities, meals, when they got up in the morning and/or retired at night and what they wore. A hairdresser visited the home each week and service users were able to decide on individual hairstyles. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 12 Separate telephones were installed in the service users bedrooms and they were able to freely make or receive calls in privacy. The menus were reflective of varied and wholesome meals being provided at the home. Several service users were observed choosing to have lunch taken to their bedrooms on the day of the inspection. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 the following standard(s): 17. The key standards were examined at the last inspection. The legal rights of the service users are protected at the home. EVIDENCE: The Inspector was advised that the voting rights of the service users were respected and that a number of service users chose to use their postal votes. Information in relation to accessing benefit entitlement, estate protection/legal issues and advocacy services, was displayed on the home’s notice board at the time of the inspection. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 22, 23, 23 and 26. The bathroom and toilet facilities at the home are sufficient for meeting the personal needs of the service users and a variety of appropriate aids and adaptations are in place. The service users’ bedrooms meet the required standards. Although the overall environment at the home was well maintained, clean and hygienic, the required standard of cleanliness was not met in specific areas and a chair in the entrance hallway was in need of repair. EVIDENCE: The bathroom and toilet facilities at the home were appropriate for meeting the private and personal needs of the service users and various aids and adaptations were in place for assisting the service users. These included wheelchairs, zimmer frames, walking sticks, assisted baths, grab rails, nurse call systems and a passenger lift. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 15 The service users occupied individual single rooms and they were suitably furnished and fitted and reflected personal choices and interests. Service users who spoke to the Inspector confirmed that they were happy and comfortable within their allocated bedrooms. The home was well maintained and essentially clean and hygienic. However, the kitchen storeroom, the kitchen windows, the back patio/garden and a strip of carpet at the entrance of the home required cleaning. A chair in the reception area was in need of repair. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 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 and 30. Standard 29 was examined at the last inspection. A requirement made under standard 27 at the last inspection had not been complied with but sufficient numbers of care staff are employed at the home to ensure that there is adequate cover during busy periods. Appropriate training for meeting the needs of the service users had been delivered to the care support staff members. EVIDENCE: The Registered Manager, Deputy Manager, two senior care support workers and two care support workers were on duty during the inspection. The Inspector was informed that two waking staff members covered duty at night. A requirement made at the last inspection under standard 27 Regulation 18(1)(a) had not been met. The Registered Manager explained that she did not accept that the number of care support staff employed at the home was insufficient for meeting the needs of the service users. The home employed ancillary staff this enabled the care support staff to focus on meeting the personal, social and health care needs of the service users. Staff members who spoke to the Inspector said that they coped well with meeting the needs of the service users but difficulties occurred during busy periods in the mornings and around meal times. The Registered Manager said that she would ensure that additional assistance is provided when required. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 17 Service users who spoke to the Inspector reported being satisfied with the standard of care and attention they received at the home. It was reflected on records viewed that mandatory training and training on adult abuse had been delivered to the care support staff. This complied with a requirement that was made at the last inspection. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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 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): 32, 35 and 36. The key standards were examined at the last inspection. The Registered Manager is experienced and appropriately qualified. A high standard of care is being provided to the service users and the atmosphere is comfortable and homely. All members of the care support staff group receive supervision at least six times annually. EVIDENCE: The Registered Manager has been is post since 1998 and is experienced and appropriately qualified. The Inspector was advised that the home endeavoured to provide a high standard of care to the service users within an inclusive and homely environment. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 19 The service users appeared comfortable and content and related positively with the Registered Manager. Members of the care support staff team reported that the Registered Manager was approachable and supportive. The Inspector was informed that apart from one service user who managed his/her own finances, Local Authorities, Solicitors or relatives were financially responsible for the service users at the home. Recordings of staff supervision seen were satisfactory and indicated that they occurred approximately every two months. Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 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. 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 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 X 3 3 3 X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 3 X X Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 21 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 OP19 Regulation 23(2) (o) Requirement The Registered Person must ensure that the garden/patio area at the back of the kitchen is tidied. The Registered Person must ensure that a chair in the entrance hallway is repaired or replaced. The Registered Person must ensure that all parts of the care home are kept clean. The Registered Person must ensure that there is additional staff cover at peak times. Timescale for action 30/12/05 30/12/05 2 OP19 23(2) (c) 3 4 OP26 OP27 23(2) (d) 18(1)(a) 15/12/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Downhurst DS0000027702.V254921.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection West London Area Office 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 DS0000027702.V254921.R01.S.doc Version 5.0 Page 23 - 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!