Inspection on 31/01/06 for Downlands Park Nursing Home

This inspection was carried out on 31st January 2006.

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

Downlands Park Nursing Home 21/11/06

Downlands Park Nursing Home 28/09/05

Downlands Park Nursing Home 15/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Downlands Park Nursing Home Isaacs Lane Haywards Heath West Sussex RH16 4BQ Lead Inspector Mrs L O’Donnell Unannounced Inspection 31st January 2006 1:00pm 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 Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Downlands Park Nursing Home Address Isaacs Lane Haywards Heath West Sussex RH16 4BQ 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) 01444 457871 01444 455812 BUPA Care Homes (BNH) Limited Mrs Kathleen Joan Hurcombe Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: Downlands Park Nursing Home is registered to provide nursing care for up to 46 Service Users in the category of older people. The home is set in landscaped grounds which back onto woodland. Accommodation is provided over two floors which are serviced by a passenger lift. All Service User rooms are single occupancy, the majority of these rooms have ensuite facilities. In addition there are two lounge areas and a mezzanine seating area, separate dining room, television room and assisted bathing and shower facilities. There is also a large activities room which accommodates a daily programme of varied activities which Service Users can access as they wish. The Registered Providers of the home are BUPA Nursing Homes Limited. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection, which took place during the afternoon of 31 January 2006. Prior to the inspection the previous inspection report was reviewed along with any other communication received. During the inspection the Inspector spoke with residents and staff and reviewed a variety of records including, care plans, administration of medication, activities, staffing and health and safety. Residents spoke highly of the staff team and of their experience of life at the home. What the service does well: What has improved since the last inspection? A weekly and monthly audit and monitoring tool has been introduced for the care planning process. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 6 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. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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 Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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): 6 Intermediate care is not a service offered at the home. EVIDENCE: People requiring respite care can be accommodated at the home, however intermediate care is not a service that is offered. However physiotherapy can be arranged at an additional fee. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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): 7, 9, 10 Each resident has a care plan in place, which provides details of their health, personal, and social care needs. Medication is administered and managed in accordance with the homes policies and procedures Residents consider that they are treated with respect and that their right to privacy is promoted by the staff. EVIDENCE: A sample of care plans was seen during the inspection. These provided information on resident’s health personal and social care needs, and the staff support and intervention necessary to meet these needs. Where particular needs are identified, i.e. nutrition, tissue integrity, detailed care plans were in place with monitoring charts and guidance for staff. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 10 In addition a new weekly and monthly monitoring and audit tool has been introduced for the nursing staff. Named nurses take responsibility for ensuring that care plans are up to date including, risk assessments, nutritional and other assessments and the key worker diary. Risk assessments are in place, however it was noted that some were in need of review, falls risk assessments in particular. All medication is kept securely and all records seen in relation to its administration were up to date. Named staff take responsibility for the ordering and recording of all medication received into the home. New systems are in place for any pharmaceutical waste with up to date records kept. A wound care chart is also maintained which records information on dressings used and when changed etc. During the inspection staff were observed to treat residents respectfully and all residents spoken with confirmed that the staff team upheld their privacy and dignity. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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): 12, 14 Daily living routines are flexible and a range of activities is provided within the home. Residents are able to exercise choice and control over their lives. EVIDENCE: It was clear through discussions with residents and staff that daily living routines are flexible and that residents are able to exercise choice in relation to getting up/going to bed, leisure and social activities and personal and social relationships etc. An activities co-ordinator is employed at the home who arranges a wide variety of activities. Activities planned for the week are displayed within the entranceway and were seen to include board games, book club, poetry reading, quizzes, organist and a film club. During the inspection residents were observed to enjoy the book club and poetry reading. The activities co-ordinator demonstrated a commitment to providing a wide range of suitable activities for the residents and all residents spoken with spoke very highly of her and her work within the home. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 12 It was clear through discussions with residents that their personal autonomy and choice are maximised. Residents confirmed that they were able to bring personal belongings with them when they moved into the home. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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): 16 There is a clear and accessible complaints procedure in place. EVIDENCE: There is a complaints procedure in place which details how any concerns or complaints can be made and how these will be dealt with. Since the last inspection it was noted that one complaint had been received. Records seen in relation to this demonstrated that it had been dealt with quickly and appropriately. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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): 20, 26 There are a range of safe and comfortable internal and external communal rooms and spaces. The home is clean, pleasant and hygienic. EVIDENCE: There are a range of communal rooms and spaces available for resident use. These include two lounges, a television room, mezzanine seating area, dining room and large activities room. All of the rooms are furnished to a high standard. Outside there are large landscaped gardens. Accommodation is provided over two floors with a passenger lift allowing residents access to both. On the day of inspection the lift was out of action to enable repairs to be carried out. This was an inconvenience to some residents Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 15 spoken with. It is however anticipated that the repairs will rectify recent problems experienced with the lift. Policies and procedures are in place in respect of infection control. Staff have access to protective clothing as necessary. There is a clinical waste disposal arrangement in place. The laundry is sited away from food storage, prepation and eating areas. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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 The needs of the current residents are met by the numbers and competencies of the current staff team. EVIDENCE: Current rotas for the home were seen and these showed that staffing levels are provided consistently and in sufficient numbers to meet the needs of the current residents. Staffing levels are usually 8 staff on the am shift and 5 on the pm shift. Staffing throughout the day is a combination of nursing and care staff. All residents spoke very highly of the staff team, with comments including, ‘they are all very good’, ‘they do all that they can’ and ‘ I cannot fault them’. In addition to care and nursing staff, there are cooking staff, kitchen assistants and domestic staff employed at the home. There are staff vacancies at the home but it was clear through discussion with staff that the current recruitment drive is proving successful. Any vacancies are currently covered through the homes bank staff or occasionally agency staff. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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, 38 The home is well managed by a suitably qualified and experienced manager. The health safety and welfare of residents and staff are promoted and protected. EVIDENCE: Standards in relation to the Registered Manager were fully assessed at the last inspection. At this inspection the Inspector was advised that the Registered Manager was currently on sick leave, however suitable arrangements had been made for the running of the care home during her absence, with the deputy manager acting up as manager with support from the Registered Providers. All records seen in relation to maintenance of equipment and service agreements were up to date. There are policies and procedures in place for all Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 18 health and safety issues including safe working practices, and staff also receive training in these areas. Risk assessments are in place and all incidents and accidents are recorded. Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 4 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X X X X 3 Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 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. Standard Regulation Requirement Timescale for action 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 Downlands Park Nursing Home DS0000024137.V280411.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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