Inspection on 06/10/05 for Downs Cottage

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Downs Cottage 28/08/08

Downs Cottage 22/08/07

Downs Cottage 06/06/06

Downs Cottage 21/12/05

Downs Cottage 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Downs Cottage 183 Great Tattenhams Epsom Downs Epsom Surrey KT18 5RA Lead Inspector Pat Collins Unannounced Inspection 6th October 2005 13:15h 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 Downs Cottage DS0000013315.V257301.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. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Downs Cottage Address 183 Great Tattenhams Epsom Downs Epsom Surrey KT18 5RA 01737 352632 01737 371068 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) Mr D Thomas Mrs N Thomas Mrs Norma Thomas Care Home 23 Category(ies) of Dementia (23), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (23), Old age, not falling within any other category (23) Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 23 registered users, one may be between 60 and 65 years of age, within the categories MD (mental disorder) or DE (dementia). Out of the 23 (twenty three) registered , they maybe either within the categories mental disorder/older persons MD(E) or dementia older persons DE(E). 2nd December 2004 Date of last inspection Brief Description of the Service: Downs Cottage is a care home with nursing for older people. Service provision includes care of older people with dementia and mental disorders. Mr and Mrs Thomas, the registered providers, are both qualified nurses and have appropriate management qualifications. They are involved in the management and administration of the home and its day-to-day operation. This two-storey property has been converted and extended over the years, retaining the domestic style and character of the building. The home has carparking facilities to the front of the premises. A spacious, secluded, enclosed garden is provided to the rear. This has suitable ramped access and a furnished patio, affording an attractive and interesting outlook from lounges and some bedrooms. The garden has mature shrubs and trees and is set mainly to lawn. Bedroom accommodation is arranged on the ground and first floor and is part accessible by chair lift. Most bedrooms are for single occupancy though there are a small number of twin rooms available if preferred. Most bedrooms have en suite facilities and all have wash hand basins and emergency call bells. Communal accommodation is on the ground floor, comprising of a combined lounge / dining room and a separate, small lounge. Assisted bathing facilities and hoisting equipment are provided. The home is within walking distance of local amenities and shops in the village of Tattenham Corner. The open countryside of Epsom Downs affords a peaceful, semi-rural environment for service users, though the home is only a short distance from a range of towns. Downs Cottage is well served by public transport. The website address for the home is www.downscottage.co.uk Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first for the year 2005/2006. It was unannounced which means staff and service users were unaware it was to take place. The duration of the inspection was over a period of six hours and thirty minutes. The visit involved follow up of progress for compliance with requirements made at the time of the last inspection. A guided tour of the home and grounds was undertaken. The inspector engaged in wide-ranging discussions with three nurses. There was opportunity to directly observe practice relating to the home’s admission and medication administration procedures. Practice observations additionally included observation of a meal served and of staff assisting service users with eating their food, also the delivery of personal care. The inspector engaged in conversations with three visitors and with five of the twenty-three service users. A number of records were examined, including care plans. These were helpful together with staffs’ approach to interacting with service users for securing service users views and enabling choice in daily routines. Staff demonstrated skill in their interpretation of the gestures and facial expressions of those service users who did not have capacity to verbally express themselves, in order to assess wishes and feelings of wellbeing. Comment cards received from six relatives/visitors to the home following this inspection. The information supplied was used to inform the inspection outcomes. The inspector would like to convey thanks to the service users, visitors and staff for their assistance and hospitality during this inspection. Also to the three nurses who competently and efficiently facilitated the inspection process. They were cheerful and helpful throughout despite many competing demands on their time. What the service does well: The home had an experienced, committed staff group. A number of staff had been employed at the home for many years affording good continuity of care and of service provision. The staff on duty demonstrated sound knowledge of the needs of service users and empathy in their attitude and conduct. A regular visitor confirmed observations of the kindness and patience of staff towards service users at all time. Comment cards from three relatives/friends of service users confirmed a high level of satisfaction with standards of care. Service users were mostly comfortable and content in their surroundings and staff interaction with them was age-appropriate and whilst informal, was Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 6 respectful. An individual who was less content in this environment was in receipt of appropriate behaviour management and her needs referred for psychiatric assessment. Staff were reassuring in their approach towards this individual. The home had established professional links with primary and specialist health professional, to the benefit of service users. Systems for regular reviews of needs involving these professionals were reported to be in place. At the time of this inspection a community psychiatric nurse was observed to visit. The appearance of service users demonstrated due care and attention to their hygiene, standards of dress and to hair and nail care. A hairdresser was cutting and setting service users’ hair at the time of the inspection. Odour control was excellent and overall the home was clean and comfortable. What has improved since the last inspection? What they could do better: A number of health and safety hazards were identified in the environment, some of which were subject to immediate action to minimise risks. These included an excessively hot radiator and water heater surface in the utility room and linen room. The doors to both areas were maintained open by magnetic devices, enabling unrestricted access by service users. Additionally, hazardous substances were accessible to service users in bedrooms, the utility room, kitchen and bathrooms. Observation of care practice in transporting a service user in a wheelchair highlighted hazardous care practice. The transfer was taking place without use of footplates. Further attention was required to pressure sore prevention practices based on observations. The need to ensure regular review of pressure sore risk assessments was discussed. A review of food safety practices was also required. The importance of ensuring food left in the fridge was covered and for staff involved in serving food and assisting service users with meals to wear suitable protective aprons or tabards was discussed. It was recommended that sacks of potatoes be stored on pallets, off the floor. The communal use of toiletries must be discontinued and toothbrushes in shared rooms must be marked to ensure adequate infection control practices. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 7 The need for improvement in pre-admission procedures was discussed to ensure adequate information is made available to prospective service users representatives. This will enable informed decisions about the home’s suitability. It was common to all relatives/visitors who returned comment cards that they were not informed that they could request access to the latest CSCI inspection report, either from the Commission or directly from the home. The National Minimum Standards also state that where practicable care plans should be drawn up in consultation with service users whenever capable and/or their representative (if any).It was not evidently the practice of staff to involve relatives/representatives in this process. Observations indicated the need to consider reassessment, by appropriate qualified professionals, of the seating and measures for maintaining the safety of the service user discussed. This is important to ensure needs are being appropriately met and to maximise safety and comfort. Attention was required to areas of the home’s administration. These include ensuring notification of all significant information to the Commission for Social Care Inspection (CSCI) in accordance with statutory requirements. Additionally for the home’s statement of purpose to be updated and accident records filed in compliance with requirements of Data Protection legislation. Storage arrangements for clinical waste required attention. Yellow bags were stacked on the ground underneath the kitchen window. Requirement was made for further discussion in this matter with the Environmental Health Officer. It should be clarified whether yellow bags must be stored in a totally enclosed container, secure from entry by animals, rodents and insects and located further away from the kitchen. Feedback from visitors/relatives in comment cards and during the inspection highlighted opinion that staffing levels were not always adequate to fully meet needs. 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. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 Attention was required to the home’s pre-admission procedures to enable prospective service users and their representatives to make informed decisions about moving into the home. Admissions to the home were on the basis of needs assessments prior to admission to ensure needs can be met and a trial period of stay offered. Overall observations confirmed the home’s capacity to meet the needs of service users. EVIDENCE: The home’s statement of purpose was located in the office and observed to require minor amendments to update the information therein. A service users guide was not available for inspection. The representatives of service users recently admitted to the home had not had opportunity to view this information or to read the home’s latest inspection report when viewing the home. This omission does not enable an informed decision for their representatives about the suitability of the home. It is acknowledged that the home’s brochure is made available however this did not provide all statutory information contained in a service users guide. Comment cards returned by Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 10 relatives and friends following this inspection all demonstrated that they were not offered opportunity to read the latest CSCI inspection report. It was suggested that this information be discussed as part of the home’s admission procedures. Admission - assessment procedures were stated by a nurse to incorporate a pre-admission assessment undertaken by staff from the home. This information was not available at the time of the inspection to enable comment on the adequacy of the home’s assessment tools. Staff relied on the care manager’s assessment, the hospital discharge summary and telephone communication from the hospital preceding the admission taking place at the time of the inspection. Also information elicited from relatives for developing a preliminary care plan for this individual. The nurse responsible for coordination this admission was clear of risks relating to the needs of this individual and of his personal and nursing needs. The same nurse advised that comprehensive risk assessments would be carried out and recorded and addressed in preliminary care plans. There was opportunity for prospective service users and/or their representative to visit the home prior to admission. Admissions were on the basis of a trial period. In sampling care plans the home’s capacity to meet assessed needs was overall demonstrated. Discussion took place with the nurse in charge based on observations that indicated need for professional re-assessment of the seating, positioning and methods for maintaining the safety a service user to ensure her comfort and to reduce risk. It is acknowledged that the inspector was informed that the multi-disciplinary team in consultation with relatives has agreed the restraint practice in use. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Care practices were underpinned by individual care plans and improvement was evident to care plans since the time of the last inspection. The need to offer opportunities for service users representatives to be involved in the care planning process was discussed. Arrangements for health care and management of medication were overall satisfactory. EVIDENCE: Service users each had an individual care plan and systems had been improved for developing and updating care plans since the last inspection. A random sample of care plans was examined, the content of which appeared generally satisfactory. Attention was drawn to an omission to record the date of review of a care plan last month. Due to levels of incapacity the service users who contributed to the inspection process were unaware that care plans were in place. Discussion with a relative confirmed that admission procedures involved establishing information about service users likes and dislikes and relevant life history information. There had been no consultation however with this relative who was the named representative of the individual visited, on the formulation of care plans. This Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 12 relative was not informed of the statutory requirement for service users to have care plans and expressed interest in future involvement in this process. Most respondents who returned comment cards confirmed satisfaction with the home’s systems for communicating important information affecting their relative/friend living at Downs Cottage. Information supplied by one relative/friend however revealed dissatisfaction in this area of the home’s operation. It was evident that where there is more than one interested party that the home’s management must ensure communication arrangements are agreed at the time of admission and monitored from time to time to ensure satisfaction and effectiveness. Service users had access to appropriate health care services. Staff confirmed a change in GP practice since the last inspection. The frequency of routine GP visits was now every two weeks. Records indicated a good level of health care and that when needs arose they were managed effectively. Equipment necessary for the prevention and treatment of pressure sores was available in the home. Observations identified the need to increase the frequency of reviewing pressure sore risk assessments for a service user with a history of recurrent pressure sores. The nurses confirmed access to advice from the tissue viability nurse specialist if needed. The training records did not evidence recent updated wound care for the home’s nursing staff. Chiropody was available by private arrangements. An optician visits and access to dieticians and physiotherapy was through GP referrals. Physiotherapy could also be arranged privately. NHS dentistry services were available. The home’s medication policy required updating to reflect changes in legislation governing the disposal of medication for care homes providing nursing care. The matron/manager was stated to be aware of changes in the disposal of unwanted medication and making the necessary arrangements. In the interim medication disposal was by the supplying pharmacy. The providers are advised to discontinue this practice. Until suitable arrangements are made a record of drugs requiring disposal should be held and these drugs boxed up and securely stored separate from supplies of current medication. Otherwise observations confirmed medication management to be overall satisfactory. Attention was necessary to record keeping ensuring nurses’ record reasons for non – administration of prescribed medication, in addition to making a record of codes on MARR charts. There were no controlled drugs prescribed or available in the home at the time of the inspection. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 The home meets these assessed standards promoting opportunities for choice and independence in service users’ lives and provision of nutritious meals. EVIDENCE: Interventions to limit independence were considered where not to do so entailed risk of harm. There was consultation with relevant professionals and relatives/representatives in this matter. There were various methods and systems for service users to express choices in areas of their daily lives. Staff were observed asking service users if they were tired and wished to go to bed and offering a choice of food from options of sandwich fillings on the menu for the evening meal. These were served with soup, a milk pudding and tea. Individual service users were observed feely walking around the home and using their bedrooms during the course of the inspection. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 14 Records of meals served indicated that a varied menu was available. A record of dietary needs and preferences was available in the kitchen. The home employed a cook daily between 08hrs to 14.00 hrs that prepared lunch and the evening meal. A kitchen assistant worked from 15.30 hours to 19.00 hrs in the kitchen and was responsible for serving the evening meal. It was stated that between 19.00 hrs and 20.00 hrs he then engaged in laundry duties. In discussion with the nurses it was evident that meals were prepared taking into account nutritional guidelines for older people. Food supplements were prescribed for individual service users. Those service users who were able to do so were served their meals sat at dining tables. The meal observed was unhurried and staff sat with service users who required assistance with their food. Service users appeared to enjoy their meal. Hot and cold refreshment were served to service users throughout the inspection. Observations of records confirmed arrangements for monitoring weights and care plans addressed weight loss and swallowing difficulties. The kitchen was generally clean however shelves appeared cluttered and in need of tidying. Records of food and of fridge and freezer and food temperatures were adequately maintained. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users were well protected by the home’s training policies for adult protection. A copy of the revised multi-agency adult protection procedures should be obtained. EVIDENCE: The home was stated to have an adult protection policy, which had been revised since the last inspection. A copy of Surrey’s multi-agency adult protection procedures was in the office. This was out of date and should be replaced with the up to date version available on the Internet. There was a rolling programme of staff training in adult protection procedures verified by staff and the training records sampled. There had been no adult protection issues at this home since the last inspection. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Mostly the home met these assessed standards, however attention was necessary to the safety of the environment. A reasonable level of accommodation was provided appropriate to the needs of current service users. EVIDENCE: On the day of the inspection the home was overall clean and tidy, warm and generally satisfactorily maintained. Whilst overall the premises were suitable to meet service users’ individual and collective needs, some hazards in the environment required risk assessment and action taken to minimise risks. For further details please refer to comments under standard 38. The exterior of the home was well maintained and the garden tidy and overall safe. Attention was drawn to a broken pane of glass in shed that was a potential hazard to staff and service users. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 17 Ambulant service users could access all areas of the home. Comment is contained under standard 38 of health and safety implications of this, which required further consideration. There was adequate communal space overall though the small lounge did not appear to be regularly used by service users. Discussed was the need to discontinue the practice of using this area for storage. This detracted from the room’s purpose and appearance. At the time of the inspection various items of equipment were stored in this area including electric kettles, a set of weighing scales with seat and a tabletop iron press. Visitors could meet with service users either in communal areas or in bedrooms. Furnishings in communal areas were domestic in character and generally comfortable and adequate. There was stated to be a rolling programme of redecoration. Lighting was domestic in nature and sufficiently bright to enable service users to read. The home was adequately heated and ventilated. The environment was secure to ensure service users’ safety. Bathing facilities were adequate to meet needs and two bathrooms with bath seats were available on the ground floor. A bathroom on the first floor was stated not to be used and usually to be locked. It was open however at the time of the inspection. Toilet facilities were evidently sufficient in numbers. Concerns were discussed however regarding health and safety hazards relating to two toilet doors on the ground floor, which opened outwards onto a narrow, main corridor. The inspector witnessed several occasions during this inspection when service users coming out of these toilets just missed injuring service users stood outside. The home had only one sluice facility serving the whole home. It is strongly advised that infection control procedure in relation to use of this sluice be closely monitored. Observations highlighted also need to review the cleaning schedules for hoist equipment and slings. Additionally the storage of a jug marked for collection of urine specimens to be stored in the sluice or alternatively the cupboard locked in the bathroom where it is currently stored. The home was fitted throughout with appropriate aids and adaptations, including assisted baths. A nurse stated the home had three airflow mattresses and other pressure relieving mattress overlays and pressure relieving air cushions. Grab rails were fitted in hallways, and in bathrooms and WCs. A chair lift was available for service users accommodated in most first floor bedrooms. There were two bedrooms on the first floor not served by the lift and service users occupying these bedrooms were required to be fully ambulant. It was not clear how the home would manage a sudden decline in the mobility of these individuals in the event the home was operating at full occupancy levels. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 18 Bedrooms sampled were clean and mostly well personalised. Service users could have their own furnishings by arrangement. Shared rooms had curtain screening between beds for privacy. Windows on the first floor were secured and ventilation achieved through opening smaller top windows. Some bedrooms were not fitted with privacy locks and it was understood there none of the service users could manage keys. The home did not comply with the National Minimum Standard for provision of lockable storage space in all bedrooms. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 Observations during the inspection indicated that competent staff that were appropriately qualified and trained addressed service users needs appropriately. Systems for continuous monitoring and review of staffing levels must be in place. EVIDENCE: Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 20 The staff rota was examined and correlated with staff on duty with the exception of management. On the day of the inspection conversations with individual staff members confirmed their opinion that staffing levels were adequate. Feedback from visitors however confirmed they observed staff to be always very busy and had little time to communicate with them. Of the six comment cards received by the inspector from visitors to the home, four considered there were sufficient numbers of staff on duty when they visited, one respondent did not complete this section and one respondent strongly expressed the view that staffing levels were not adequate. There was always a qualified nurse on duty at each shift. Ancillary staff was employed in sufficient numbers and there were no staff employed in the home below 18 years of age. Arrangements for staff training were not fully assessed on this occasion. It was evident from the available information that some staff training had taken place since the last inspection. Observations identified the need for statutory moving and handling refresher training to be arranged. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 37 and 38 The home is operated and managed by a competent, suitable qualified manager who provided leadership to staff. Observations indicated the need for an increase in management and administrative hours however and improvement in risk assessment and risk management procedures. EVIDENCE: The providers evidently had defined areas of responsibility for the home’s management and administration. Observation of the rota in recent weeks suggested a shortfall in management hours however it was noted that the records of management hours were not being accurately maintained. Observations confirmed that whilst the management of the home was based on sound procedures and policies, aspects of management practices required review and improvement. Specifically attention was necessary to risk Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 22 assessments and environmental health and safety matters, to the storage of accident records, to staff training and pre-admission and admission procedures. Examples where improvement is warranted to staff training and admission procedures are given in the relevant section of this report. Health and safety concerns not already addressed included observation of an excessively hot radiator surface in the utility room and hot surface of a boiler heater in a linen room. Both doors to these areas were secured open by staff giving service users unsupervised access to these hazardous areas. Whilst it was acknowledged that some hazardous chemical were stored in lockable cupboards there was noted to be other hazardous substances accessible to service users. Washing powder and washing liquid chemicals were openly accessible in the utility room. Washing up liquid was available on open shelving in the kitchen and toiletries that posed a potential risk of being ingested by service users were openly stored in bathrooms and bedrooms. It was not evident that unrestricted access to these substances was subject to regular risk assessment resulting in risk management strategies and to review. Throughout much of the duration of the inspection the kitchen door was observed left open and service users had unsupervised access to this area where there were numerous hazards, at times. This was drawn to the attention of the nurse in charge who closed this door on a number of occasions. It was later observed that staff had left the door ajar and this area again accessible to service users. Observations confirmed the rights and best interests of service users were safeguarded overall by record keeping practices and policies. Attention was drawn to omissions in notifications to the Commission in accordance with statutory requirements. It was recommended that the providers obtain a copy of the relevant guidance from the Commission for staff’s reference. Attention was also required to the storage of accident records. The statement of purpose and medication policy required updating. From discussions with staff, there was evidence that the manager operated an open door policy with staff. There were regular staff meetings held and staff were encouraged to bring any ideas for improvement to staff meetings. Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 23 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 2 1 Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 5(1)(2) (2)(a) Requirement For a copy of the service users guide to be made available to prospective service users’ and/or their representative including access to the latest inspection report. For the statement of purpose and service users guide to be updated. The service users guide must contain a copy of the latest inspection report and must be accessible to service users representatives. For records of pre-admission assessments carried out by staff to be accessible to staff at the time of admission and maintained on service users files. For further review of the needs and suitability of provision for seating for the individual discussed to ensure needs are comfortably and appropriately met. Also for continuous review of measures in place for ensuring this individual does not fall out of the wheelchair to minimise other risks. For the care planning process to DS0000013315.V257301.R01.S.doc Timescale for action 06/11/05 2 OP1 6 (a) 06/12/05 3 OP3 14(1) 17(1)(a) Sch1(a) 12(1)(a) 14(2)(a) 06/11/05 4 OP4 20/10/05 5 OP7 15(1)(2) 06/12/05 Page 25 Downs Cottage Version 5.0 (c) 6 7 OP8 OP8 12(1)(a) 13(4)(c) 13(3) 8 OP8 13(2) 9 OP15 12(1)(a) 16(2)(g) 10 11 OP27 OP38OP19 18(1)(a) 12(1) 13(4)(a) (b)(c) involve consultation with service users representatives’ where practicable and appropriate. For regular review of tissue viability assessments. For the practice of communal use of toiletries to be discontinued. Additionally for toothbrushes for service users accommodated in shared rooms to be clearly marked/labelled. For the medication policy to be updated and records to include reasons for non – administration of prescribed medication. It was noted that arrangements are being made for proper disposal of medication. For review of food safety to include provision and use of protective aprons or tabards for care staff involved in serving food and assisting service users with meals. Also for food stored in the refrigerator to be covered. For staffing levels to be reviewed. For risk assessments to be in place and regularly reviewed to address health and safety hazards to service users in the environment. This include the following hazards identified at the time of the inspection: • Excessively hot unguarded radiator accessible to service users in the utility room. • Excessively hot surface of the boiler in the linen room nearest the utility room, accessible to service users. • Hazardous substances accessible to service users openly stored in the laundry room, kitchen, bathrooms and bedrooms. DS0000013315.V257301.R01.S.doc 13/10/05 06/11/05 20/10/05 06/11/05 06/11/05 09/10/05 Downs Cottage Version 5.0 Page 26 12 OP38OP20 12(1)(a) 13(4)(a) (c) 10(1) 16(2)(k) 13 OP38OP26 14 OP30OP31 18(1)(a) (c) (i) 15 16 17 18 OP31 OP31 OP37 OP37 10(1) 10(1), 37(1)(2) 17(1) 17(1)(a) Sharp edge of a damaged windowpane in the shed. • Risk of injury from doors of two toilets nearest the office which open outwards onto a narrow corridor which is a busy thoroughfare constantly used by service users and staff. • For staff to be instructed in the use of footplates when transporting service users in wheelchairs. An action plan must be produced and instituted for reducing these risks within the time scale set. For the small lounge not to be used for storage of equipment which in addition to detracting from the character and purpose of the room, is unsafe. For suitable provision to be made for the storage of clinical waste, specifically yellow bags awaiting collection. Consultation must take place with the Environmental Officer to establish requirements in this matter. For the staff training programme to include statutory updates for all staff in moving and handling. Additionally for regular wound care refresher training for nurses. For review of management hours to ensure adequacy of current arrangements. To ensure notification of all events in accordance with statutory requirements. To ensure records of management hours are maintained up to date. For accident records to be stored in accordance with requirements DS0000013315.V257301.R01.S.doc • 06/11/05 06/11/05 06/12/05 06/11/05 20/10/05 13/10/05 13/12/05 Page 27 Downs Cottage Version 5.0 of the Data Protection Act. 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 3 4 5 Refer to Standard OP15 OP18 OP24 OP38 OP38 Good Practice Recommendations For the storage of potatoes off the ground, on pallets. For the home to have a copy of the revised multi-agency adult protection procedures. For all bedrooms to be fitted with safety locks and for a rolling programme to be instituted for provision of lockable storage space in each bedroom. To consider not maintaining doors to the utility area and linen room where there are potential hazards for service users in the open position. In any future plans for upgrading the premises to consider conversation of the two ground floor toilets near the office into a disabled toilet, fitting a sliding door to reduce the hazards posed by these doors opening outwards. To bolt shut the sluice room when not in use. To store the jug used for the collection of urine specimens in the sluice or in a locked facility in the bathroom. 6 7 OP38 OP38 Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Downs Cottage DS0000013315.V257301.R01.S.doc Version 5.0 Page 29 - 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. 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