Inspection on 06/09/07 for Downhurst

This inspection was carried out on 6th September 2007.

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 22/09/06

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 Jane Collisson Key Unannounced Inspection 6th September 2007 11:05 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.V349062.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.V349062.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 Rea Banks Williams Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 26 22nd September 2006 2. 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 threestorey 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 residents and its categories of registration are old age and physical disabilities although not all areas of the home are suitable for people with poor mobility. There is accommodation for twenty four people in single rooms with the one double room currently used a single room. There are four bathrooms and eight toilets. The home has one large lounge and a separate dining room in the main house, with two lounge/dining rooms in the rear building. There are other areas, including the walkway, which can be used as quiet areas. There are well-maintained gardens around the home, with places to sit including a patio. There are several offices located throughout the building. One small room is set aside for residents who smoke, in line with new legislation. Downhurst is owned and managed by Ealing Eventide Homes Limited, a notfor-profit organisation. There is a board of Management. The home has a Registered Manager, Deputy Manager, four senior staff, and a team of day and night Support Workers. There is an administrator, a handy person, a gardener, two cooks, a kitchen assistant, laundry and domestic workers. The current fees are £480 per week. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 6th September 2007 from 11.05am to 5pm. An Expert by Experience accompanied the Inspector. The Commission for Social Care Inspection is trying to improve the way it engages with people who use services so as to gain a real understanding of their views and experiences of social care services. It now uses ‘Experts by Experience’ who are an important part of the inspection team and help Inspectors get a picture of what it is like to use a social care service. The term ‘Expert by Experience’ used in this report describes a person whose knowledge about social care services comes directly from their experience of them. The Registered Manager, who has been in post since December 2006, was present throughout the inspection. The Deputy Manager was also available and four care staff were on each of the early and late shifts. The ancillary staff met included the cook, the kitchen assistant and domestic staff. The Expert by Experience and the Inspector toured the home with the Registered Manager. He had lunch with a group of the residents and spoke to several more residents throughout the home. His findings have been incorporated into the report. He said, in summary, “All in all, I would say it reasonably meets the criteria and standards it lays out in the home’s brochure. A pleasant place to live in, and in pleasant surroundings”. A keyboard player was entertaining the majority of the residents, in the largest of the communal lounges, during the morning. He also undertakes a magic act at some of his visits. The main activity of the afternoon was a bingo session, which is run by one of the management committee. Three members of the management committee were in the home during the day. One family met during the inspection were very appreciative of the way in which their relative had been settled into the home. An additional visit was made on the 10th September at 1.30pm to meet with the financial administrator to check on the finances held for the residents. Feedback was given to the Registered Manager on both of the inspection days. She completed the Annual Quality Assurance Assessment to the Commission for Social Care Inspection, which provides a self-assessment describing the areas where the home does well, where it could do better, and its planned improvements. In addition, statistical information on residents, staff and the service, including support, maintenance, policies and procedures is completed as part of the assessment. Samples of records examined on this inspection included care plans, recruitment files, medication administration and maintenance files. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 6 No specific cultural needs were required to be met at the time of this inspection, but those requiring their religious needs to be met are assisted to do so by visitors from various religious denominations and by the opportunity to visit places of worship. At the last inspection in September 2006, three requirements were made. Six have been made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The home’s Statement of Purpose and Service Users’ Guide have not been fully updated for some time and need to be reviewed on a regular basis. The Statement of Purpose must also be amended to include the information to demonstrate how the needs of people who are not within its category of registration, including those with dementia, are met by the home’s staffing levels, activities and environment. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 7 The medication policy is in need of updating to be in line with the current guidance and good practices. While there is ongoing redecoration in some areas of the home, and a new lift is to be installed, there are areas where upgrading must be considered to ensure that a good standard is maintained. This includes refurbishment of the kitchen. It is also recommended that the unused bathroom is considered for upgrading. The Registered Providers are required to provide an Action Plan to demonstrate its future plans for improvement and the timescales for undertaking the work. Although there has been a minimal amount of recruitment since the Registered Manager has been in post, the evidence from the files examined showed that a more robust procedure is needed to ensure all of the required information has been obtained. The information needs to be kept in better order to evidence that good practice is being followed. While a training programme has been identified, and the Registered Manager is taking action to upgrade the training, it must be ensured that all of the staff have undertaken the basic courses they require, such as moving and handling, within the timescale given. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 8 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.V349062.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 (6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The documentation for admission and assessments are in place, and being used, but are in need of some reviewing and updating. Prospective residents are encouraged to assess the facilities and suitability of the home before admission by making several visits. Action is being taken to make the home more suitable for people with poor mobility. EVIDENCE: Residents are provided with copies of the Service Users Guide in their bedrooms. However, the Statement of Purpose and Service Users Guide require some updating including information regarding the Registered Manager. Information also needs to be included on how the needs of the people, being considered for admission or already in the home, who are not within the home’s categories of registration. The home’s environment, staffing levels and activities need to shown to be taken into consideration. A small Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 10 number of the residents have dementia and the Statement of Purpose must include information about how their needs can be met. The Registered Manager said that the Service Users Guide could be produced in large print, if it is needed. Although the current Guide contains the information required, it is recommended that a more “user friendly” Guide is produced when the documentation is reviewed. The Registered Manager confirmed that contracts/terms and conditions are in place for the residents. These have been have been reviewed, reissued and signed since the Manager has been in the post. A sample of four residents’ files was examined. Where residents are referred through the care management process, by Local Authorities, assessments are received. The majority of residents are not referred through this system and the Registered Manager was aware that the documentation for the assessment procedures had been in need of improvement and has commenced this process. The home has been open for more than fifty years and a number of areas have been in need of upgrading, particularly to suit the needs of people with poor mobility. It has now been agreed that a lift will be provided in the building to the rear of the home, which will reach all of the floors where there are bedrooms. Currently, the residents moving into this part of the home must be able to use the stairs. Several of the residents are quite independent, but others are frail and one resident has been assessed as needing nursing care and was awaiting a placement. The Registered Manager discussed how she ensures that people who wish to come into the home are assisted to make the choice. They are encouraged to visit on as many occasions as they wish. One family spoke positively of the way in which their relative had been admitted to the home and praised the staff for their helpful attitude. The home does not have an Intermediate Care unit, so this standard was not assessed. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place but it is acknowledged, by the Manager, that they could be improved and the residents more fully involved in planning their care. Health needs are met by community services. The medication procedures are satisfactory but the policy is in need of updating. Residents feel that they are well treated, have choice and are consulted about their daily life in the home. EVIDENCE: Four residents’ care plans were examined in detail and found to be satisfactory. However, the Registered Manager has plans to make changes to these as she would like them to be more person centred, detailed and be easily accessible to the resident themselves. The Registered Manager acknowledged that the risk assessments also need to be improved. At the present time, none of the residents were in need of using a hoist but the moving and handling assessments still needed to be more detailed. She has introduced more assessment procedures into the home including those for nutrition, and pressure areas. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 12 The health needs of the residents are being met by community services. A number of general practitioners visit the home and residents have access to dentists, optician and chiropody within the community. It was noted in one of the care plans examined that a medication review had just been undertaken by the general practitioner. District nurses visit the home on a regular basis to carry out the nursing tasks that are required. The Registered Manager said that there was a good working relationship with the district nurse and gave an example of how a resident’s medication was supervised by them. The current medication system is supplied in weekly dosette boxes. A sample of the medication was checked, including non-dosetted medication, and found to be satisfactory. Residents who are able to self medicate are encouraged to do so, with regular monitoring carried out. An audit by the pharmacist was due the day after the first visit and the Registered Manager supplied a copy of the report. This had no requirements but it was noted that there was no policy on homely remedies. A copy of the medication policy was supplied which, although signed as reviewed in 2007, was originally dated 2003. This needs to be reviewed in line with more recent guidance and include the policy on homely remedies, “as and when” medications and any specialist needs that the home may be asked to meet. The residents spoken to were positive about the way in which they are treated by the staff. People said that the staff are “very good”, and provide them with the support they require. The home has included in its Service Users’ Report, based on questionnaires and meetings, the subject of personal care. Those surveyed all said that they were treated with dignity and respect when given personal care. All of the rooms have single occupancy, which supports privacy. A discussion was held with the Registered Manager regarding the way in which residents are supported when their health deteriorates or they need to move on to nursing accommodation. She has undertaken “end of life” training with some of the staff to help them to support the residents in these circumstances. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A regular and varied programme of activities is available which residents enjoy and about which they are consulted. Religious needs are being met. People have choice over their daily lives and the way in which they prefer to live. People were positive about the meals and have a good choice. Staff were sensitive to the needs of people who need assistance with their food. EVIDENCE: On the day of the inspection, two group activities were taking place in which most people participated. A regular programme of activities is provided and publicised. Entertainers visit the home regularly and the home’s committee members run bingo sessions twice a week. People were very appreciative of these. Three staff have attended an activities training workshop. One resident is able to continue to play the piano, sometimes for the other residents. The home is situated in a pleasant residential area of Ealing, with the shopping area of Ealing Broadway within a reasonable distance. Buses pass the home. Many of the residents like to participate in religious activities, either within the home or by visits to churches, and the home has links with the nearby Ealing Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 14 Abbey. The Registered Manager said that Church of England, Roman Catholic and ecumenical representatives all visit the home. The Expert by Experience and the Inspector saw the photographs and a press report of the “Downside Olympics” which had taken place in the garden, involving residents and staff. The Registered Manager said that they were planning and looking forward to celebrating the home’s 60th anniversary in 2008. People who were spoken to during the inspection were very positive about the opportunity for activities and outings. People confirmed that family and friends are welcome to visit and one family was met. There are areas where people can meet privately if they wish to do so. The Registered Manager said that a “League of Friends” is being considered as a way of family and friends becoming involved. Several residents prefer to remain in their rooms, rather than in the communal areas and their choice is respected. The Expert by Experience said that “generally speaking, I felt that most of the residents seemed integrated into a social pattern”. However, he felt that one person, who appeared isolated, might be encouraged to mix just occasionally with other residents but acknowledged that this might not be the person’s wish. The gardens are very popular and some people enjoy taking exercise as well as enjoying sitting on the patio. The garden can also be viewed from the corridor, which links the two buildings, where there are seats and staff and other residents pass by. There is a choice of two main meals at lunch. The tables were nicely laid. The Expert by Experience noted that, where two people were being assisted with their meals, “this was done without pressure on the persons being helped” He also sat with a group of residents at lunch and sampled the meal of cottage pie. An alternative of chicken was available. He reported that the meal was “wholesome, good basic cooking and plenty of it”. There were no specific cultural needs to be met in regard to food at the present time. The evening meals consists of a variety of choices, including soup, sandwiches, salad or a hot snack, such as fish fingers, cheese on toast or quiche. The kitchen is part of the original Victorian building. A new cooker was on order. The extractor fan had been repaired but was still quite noisy. Although kitchen was found to be in a reasonable state of cleanliness, the age and fabric of the building does not assist this process and serious consideration needs to be given to upgrading the kitchen within a reasonable timescale. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An open culture is encouraged and people were happy with the service provision. Information is available to enable people to make complaints and the procedure is supplied to everyone. The safeguarding of adults training needs to be extended to all staff to ensure a good understanding of the procedures. EVIDENCE: There had been no recorded complaints in the home since the last inspection. Information on making complaints is included in the Service Users Guide which is supplied to everyone. People were positive about being able to raise their concerns should this be necessary. The Registered Manager has introduced a “suggestion box” in the hallway for residents and visitors but it had not yet been used. The Registered Manager confirmed that people who wish to do so are enabled to exercise their right to vote, with a postal vote if required. Not all of the staff have had training in the safeguarding of adults and this needs to be extended to the whole staff team. One issue was brought to the attention of the London Borough of Ealing’s safeguarding adults officer and the Commission for Social Care Inspection in early 2007 but, following a meeting, was found to be an issue regarding a resident’s immobility and was resolved by a move to a more suitable room. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and efforts are being made to ensure that the needs of everyone, particularly those with poor mobility, can be met in the future. However, because of the age of the buildings areas, such as the kitchen, are in need of upgrading. The management of infection control has improved and the home is clean and fresh. Residents are encouraged to personalise their rooms. EVIDENCE: The home has been opened for nearly sixty years. There is a variety of accommodation, provided in the original period house and the extension to the rear of the home. At the present time, the large house provides a large lounge and separate dining room. The Registered Manager has discussed with the residents a possible change to make the two rooms into two lounge/dining rooms. This would provide the opportunity for two smaller units, possibly Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 17 providing a more comfortable environment for conversation and for watching television. To the rear of the home, there are two lounge/dining rooms. One was in the process of being redecorated and refurbished with a kitchenette area, as a grant from the Department of Health had been received. In addition to the lounges and dining rooms, there are seating areas in the corridor which links the house and overlooks the very attractive gardens. The home has four bathrooms, two with assisted baths, one with a shower and a fourth that does not have any equipment and is not generally used. The Registered Manager said that they meet the needs of the current residents. While the number just meets the National Minimum Standards, it is recommended that the fourth bathroom is considered for refurbishment in the home’s future development plans to ensure a wide a choice as possible, particularly with the lack of en suite bathing facilities in the home. Although the large house has a lift, the rear of the home does not have one. This has meant that the residents have had to have good mobility to access the bedrooms. However, the funding has been arranged for a lift to be installed and this is planned for the next six months. The work is estimated to take sixteen weeks and the Registered Manager was thinking of ways to minimise the disruption to the residents, although some will be inevitable. The bedrooms vary in size, some in the older part of the home being very large, others are quite small and under the National Minimum Standard of 10 sq. metres. People are encouraged to personalise their rooms and, where space permits, can bring items of their own furniture. Bedrooms seen were pleasantly furnished. The family of one recently admitted resident were very pleased with the way in which the staff had helped to personalise the room. The Expert by Experience commented on the age of the building and said that Downhurst is “a residential home of its time” and “may be seen as being a bit ‘cramped’ ”. He felt that not having en suite toilet/bathing facilities was “another downside”. However, this is mitigated by some of the larger bedrooms, the pleasant surroundings, including the communal spaces and attractive gardens, which do give the residents choice and space to move around. The home was found to be clean and fresh. The Registered Manager took action after her appointment to improve the cleaning regime in the home, introducing more robust infection control systems. National Vocational Qualifications are being introduced for ancillary staff to develop their skills. There are areas of the home, such as the kitchen, that would benefit greatly from upgrading and this needs to be considered in the near future. The Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 18 Registered Manager is aware of the areas which need improvement and the Committee needs to consider how these will be progressed. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient staff to meet the needs of the current residents and a permanent staff team has provided a good level of continuity. Better recruitment procedures are needed when new staff are recruited to evidence a more robust process has been undertaken. Training is encouraged and is improving but the Manager is aware of gaps in the training programme. EVIDENCE: The home’s basic staffing levels remain the same as at previous inspections. Four staff are on during the day shifts, which includes a senior, and there are two staff during the night. In addition to the Registered Manager, there is a full-time Deputy Manager. The Registered Manager has changed the staff rotas to provide a more efficient use of staff time. Staff spoken to were positive about working in the home and many have done so for some time, which has provided a good level of consistency for the residents. The Registered Manager said that none of the residents required the use of the hoist for moving and handling. Many of the residents are mobile but all use the bathrooms with assisted facilities. The staff training records showed that not all of the staff have been trained in manual handling and this needs to be Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 20 rectified as soon as possible. The Deputy Manager, who is a trainer, was due to update her moving and handling training to enable her to train the staff. A selection of the home’s recruitment records was examined at the second visit to the home. All of these were completed prior to the Registered Manager being in post and she had not been involved in recruiting any care staff. Because of staff leaving, she was about to start the process to fill the vacancies. She is aware that the record keeping needs to be improved to maintain the files in better order. In the records examined, there were gaps in the employment records, two references had not always been obtained, and the dates of employment were not always recorded on the references. Staff were seen to have Criminal Records Bureau disclosures. The designation of the person supplying the reference needs to be clear and whether or not it is in a personal capacity. The Registered Manager showed an awareness of what is needed when she commences the recruitment. The current files need to be put into better order so that information can be easily accessed, should be it needed. The Registered Manager reported that the home employs a company to provide legal advice and information on employment matters should they be required. One staff disciplinary matter was being managed at this period. Until recently, the majority of the training courses have been held within the home and carried out by one of the Committee members, who is trained to do so, or the Registered Manager. The Registered Manager is now accessing some of the training from external sources and finding that this is beneficial to the staff team to widen their expertise. She undertakes training such as communication and equalities herself, as well as food hygiene and health and safety. The home has a good record of National Vocational Qualification training and aims to have all of the staff, including domestic staff, trained. Seven of the fourteen care staff have Level 2 or 3 NVQ. A further five are working towards Level 2. However, the training records provided by the Registered Manager did not demonstrate that all of the basic training courses were up-to-date, although some had been booked for October 2007. The Manager needs to identify the staff most in need to undertake the essential courses, such as manual handling and first aid, and ensure that these are completed within a reasonable timescale. There is a Skills for Care induction record being used in the home. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience to manage the home. She has a clear understanding of the principles of care and support, encouraging people to remain independent and have choice over their lives. Most record keeping is satisfactory but would benefit from a thorough review to bring the systems up-to-date. The Registered Manager is aware of, and has commenced, changes to benefit both residents and staff which is being achieved through consultation and the promotion of an “open door” policy. EVIDENCE: The Registered Manager has been in post since December 2006 and had been registered with the Commission for Social Care Inspection recently. She has five years’ experience of care home management, and thirty years in health care. She has undertaken the Registered Managers Award and was previously Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 22 a nurse. The Registered Providers of the home are the Ealing Eventide Homes Ltd. Members of the Committee are frequently in the home and the Chair of the Committee provides supervision for the Registered Manager. It was noted throughout the inspection that the home has an open and relaxed atmosphere. A number of residents visited the Manager’s office with queries or just to pass the time of day. The Registered Manager discussed with the Inspector and the Expert by Experience that she was keen to make the home as “non-regimented” as possible, being led by the residents themselves to decide how they wanted the home to be run. However, she was aware that regular monitoring was always required to ensure that needs were being met. The Registered Manager has produced a Service Users’ Report dated from April to June 2007. The home has used the National Care Association’s Quality Assurance monitoring tool to gain the views of residents. This includes questions each month, to a random sample of residents, about an area of service. In March, April and June the subjects were food, personal care, and activities. The introduction of residents and relatives’ meetings has taken place since the Registered Manager has been in post. Members of the Management Committee visit the home monthly, under Regulation 26 of the Care Home Regulations 2001, and provide a comprehensive report, which includes information about the residents and staff they have spoken to and the records checked. On the second visit to the home, the finance officer was met and she showed the Inspector the way in which the finances of the residents are held. The system was satisfactory but there are elements of the way in which records are maintained which can be improved, including the documentation. The Registered Manager was aware of the changes that are required, such as the signing of withdrawals by the resident themselves, wherever possible. Checks of the finances are undertaken by the Management Committee. The Registered Manager and Deputy Manager have both undertaken training for the supervision of staff. The Registered Manager said that she is working towards the National Minimum Standards of six supervision sessions a year but this has not been reached yet. In the files examined, limited supervision sessions were seen to have taken place, prior to the Registered Manager being in post. As mentioned elsewhere in this report, the Registered Manager has started to address the issues around record keeping and has already made some progress. It was noted, from the Annual Quality Assurance Assessment, that all of the policies and procedures had been reviewed in 2007 but it needs to be shown that, as in the case of the medication policy, these are fully reviewed and updated on a regular basis. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 23 The home has had a comprehensive fire risk assessment produced and a copy was supplied to the Inspector. A new alarm panel has been installed. A sample of the fire records was examined. The fire alarm and fire equipment tests had been undertaken in August 2007. The Registered Manager said that one of the Management Committee members is becoming familiar with the fire precautions for the home to help support good practice. Information was provided by the Registered Manager on the Annual Quality Assurance Assessment, regarding maintenance and other tests. The Legionella testing has been carried out in February 2007, the gas and the emergency call system were checked in January 2007. The lift had been serviced in February 2007 and the hoist and slings in August 2007. The Environmental Health Officer had visited the home in January 2007. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4&5 Requirement The Registered Manager must ensure that the Statement of Purpose and Service Users’ Guide are reviewed on a regular basis and updated as required. The Registered Manager must ensure that the Statement of Purpose includes the information as to how the needs of people who are not within its category of registration, including those with dementia, are met by the home’s staffing levels, activities and environment. The Registered Manager must ensure that the medication policy is reviewed in line with current guidance. The Registered Providers must provide an Action Plan giving details of the areas of the home which require upgrading and the timescales that are planned for the work. This needs to include the kitchen. The Registered Manager must ensure that recruitment records are maintained in good order, with all of the information DS0000027702.V349062.R01.S.doc Timescale for action 30/11/07 2 OP1 4 (1) (a) (b) 30/11/07 3 OP9 13 (2) 31/12/07 4 OP19 23 (1) (a) 31/12/07 5 OP29 19(1),17 (2) Sch 4 30/11/07 Downhurst Version 5.2 Page 26 6 OP30 18 (1) (c) (i) required to demonstrate robust procedures are in place. The Registered Manager must ensure that all staff have the training to carry out the work they undertake. This includes manual handling, safeguarding adults and health and safety. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP21 Good Practice Recommendations That the Service Users Guide is produced in a more “user friendly” format when it is reviewed. That the bathroom not currently in use is refurbished to provide further assisted facilities for the residents. Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Downhurst DS0000027702.V349062.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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