Inspection on 04/12/06 for Downside House

This inspection was carried out on 4th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Downside House 18/07/07

Downside House 30/12/05

Downside House 10/02/05

Downside House 09/07/04

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

CARE HOMES FOR OLDER PEOPLE Downside House 3 - 4 St Boniface Terrace Ventnor Isle Of Wight PO38 1PJ Lead Inspector Liz Normanton Unannounced Inspection 4th December 2006 09:30 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 Downside House DS0000044123.V315953.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. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downside House Address 3 - 4 St Boniface Terrace Ventnor Isle Of Wight PO38 1PJ 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) 01983854525 01983 853606 Downside House Limited Mrs Keeley Groundsell Care Home 21 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (1) Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate two named people over the age of 65 years in the MD(E) category One named person under the age of 65 years can be accommodated in the LD category 30th December 2005 Date of last inspection Brief Description of the Service: Downside House is situated within St Boniface Terrace, Ventnor and has wide sweeping views across the English Channel and St Boniface Down. The home is a combination of two Victorian town houses conjoined to create one premises, which has recently been tastefully extended. Accommodation is split between three floors all serviced by a passenger lift, the fourth floor comprising office space, training room and staff accommodation. The amenities of the local town are not easily accessed on foot, given the local geography, although public transport is accessible at the end of the road and the manager and staff often provide transport to the town if required. The home is currently registered to provide care and accommodation for up to 21 older people including up to 5 people over 65 years with additional physical disabilities, 3 persons over 65 years with mental health problems and 1 person under the age of 65 with a learning disability (this condition is for a named person only). Weekly Fees From: £355.11 - £435.05 Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 04/12/06 and focussed on what the commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards and looked for evidence of compliance with regards to requirements made at the last inspection. The information in this report has been collected from a variety of sources, which includes a pre-inspection questionnaire completed by the manager, four resident’s feedback questionnaires a visit to the home, discussion with several residents, manager, deputy manager staff and one relative. Four residents’ care files and three staff files were audited. At this inspection it was found that new staff had been employed prior to the manager having obtained clearance from the Protection of Vulnerable Adult (POVA) list. The manager had complied with the majority of requirements made at the last inspection however there is still work to be finished off following the building of the extension. Further requirements have been made at this inspection. There have been some improvements in the fabric of the home since the last inspection. Comments from residents indicated that the majority are satisfied with the service the home provides. What the service does well: Prospective residents and their representatives are provided with the homes information pack, which enables them to make an informed choice. The home will not admit any prospective residents until they are satisfied that the individuals needs, can be met. The home ensures that everybody has access to the individual health provision and support they require. There is a range of activities to provide social interaction and mental stimulation for the residents. Residents are encouraged to maintain their independence and make choices on how they wish to live. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 6 The food is of a good quality and residents are offered alternative choices. The home provides the residents with a homely environment with comfortable well - decorated surroundings. Each, resident is provided with their own room which is fitted with an en-suite and they are able to personalise the room to their taste. The staff team are well trained with over half having completed qualifications in care. The home is well managed and administered by a competent experienced qualified manager. What has improved since the last inspection? What they could do better: The home must provide residents with a contract which includes the terms and conditions of the placement. The manager must ensure that those staff responsible for the drawing up and reviewing of care plans undertakes their role and responsibilities to ensure that care plans are always available, accurate and up to date. The home must ensure that all residents responsible for self- medication have had a risk-assessment and have signed a form stating that they are responsible for the safekeeping and administration of their own medication. The manager must ensure that recruitment procedures are robust to ensure the ongoing safety and welfare of the residents. Now that the extension is complete the manager should concentrate on completing unfinished internal works and attend to general repairs. The manager must ensure that staff, are provided with formal supervision at least 6 times a year. The manager must ensure that the cooks adhere to the homes health & safety procedures. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 7 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. Downside House DS0000044123.V315953.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 Downside House DS0000044123.V315953.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does provide prospective residents and their representatives with information needed to choose a home. There was no evidence that residents are in receipt of a contract of terms and conditions of the placement. The home does not admit prospective residents until it is satisfied that their needs are met. EVIDENCE: In discussion with the deputy they reported that prospective residents are given an, information pack, which contains the statement of purpose and service user guide, sample contract and scale of fees. The deputy was not able to provide evidence of the information pack and explained that they had Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 10 sent out the last one. Those residents spoken with could not remember whether they had a pack or not. The manager was not able to provide copies of resident’s contracts, but reported that each resident does have one. In discussion with the manager they reported that fees are raised annually and that residents are informed of fee increases by letter. Two letters of evidence were viewed. In discussion with the deputy they reported that all prospective residents have an assessment of need undertaken prior to admission to ensure that the home can meet their needs. The inspector viewed three of the most recent residents files and found them to contain evidence of a comprehensive needs assessment. Prospective residents or their representatives are invited to visit the home to meet the staff, other residents and view their room to enable them to make an informed choice as to whether the home will meet their needs. One resident spoken with confirmed that her family had been to view the home on their behalf. Downside House DS0000044123.V315953.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally provides each resident with a comprehensive care plan. However on this occasion two of the most recently admitted residents did not have care plans. This could be detrimental to their care as staff would not have the relative information they required to provide consistency of care to meet each individuals needs. Resident’s health care needs are met. The principles of respect, privacy and dignity are put in to practice and residents feel valued. EVIDENCE: The inspector viewed three files of those residents most recently admitted and found that they did not contain care plans. Following a search around the office by the manager and deputy one care plan was found which had not been Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 12 filed. There was evidence that this care plan had been reviewed. It was evident that the manager and deputy where surprised by the absence of these documents as they reported a senior member of staff is responsible for this task and were genuinely surprised that care plans had not been done. Both agreed that the care plans would be drawn up the following day following discussion with the person responsible. A fourth resident file was viewed and was found to have a care plan and this had been regularly reviewed. All files viewed contained a risk-assessment. In discussion with a member of staff they reported that residents are not involved in the review of their care plans. Those residents spoken with did not appear to know that they had a care plan. In discussion with one resident they said that they were very happy with their care, they had begun to learn life-skills, which they had never experienced before whilst being cared for by their parents and that they were becoming more independent. There was evidence that resident’s health care needs are met, all residents are registered with a general practice and records of GP visits to the home. In discussion with a visiting district nurse, they reported that they had visited the home twice and on both occasions they had seen their patient in private. A chiropodist visits the home regularly. Residents were observed to be wearing spectacles and hearing aids as required. The home has obtained a number of hospital beds, and specialist equipment to promote residents with limited mobility independence and support staff in transfers. The home has a medication policy and procedures which are accessible to staff. Medication records where up to date for each resident. Medication is recorded coming in to a leaving the home. There is safe storage of medication including controlled drugs. In discussion with the deputy they reported that most staff working at the home had been trained in medication administration. One resident self-medicates as required with painkillers which were observed to be kept in their room, when asked where they kept them the resident pointed to an unlocked draw in chest of drawers. The home had not followed its medication procedure for self-administration. There was no riskDownside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 13 assessment in place and the resident had not signed the homes selfadministration document. The medication was not being stored safely although the manager reported that there was a lockable cupboard in the residents, room. During the inspection visit residents were observed having positive interactions with the staff and in discussion with several residents they confirmed that they are always treated with dignity and respect. A small number of residents had their own phones in their bedrooms to allow them privacy. One resident took a call from their relative and asked to use the office, which was vacated to allow them privacy. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 14 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. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The home offers residents a variety of social activities, which includes movement to music, listening to music, card making, bingo, reading of local newspapers with group discussion, hand massage and foot spa. The staff team are responsible for providing the daily activities and change them on a weekly basis. The home does not display activities on a notice board as residents are notified verbally of what’s on. In written feedback from four residents three stated they liked the activities on offer whilst one was not able to participate. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 15 At the inspection visit the inspector did not see residents partake in the movement to music in the afternoon but several residents confirmed that they had really enjoyed it. In discussion with the deputy they reported that the home hires a mini-bus and residents have the opportunity to go out for a drive in the countryside or to the seaside every 3 weeks. The home is hoping to be able to extend this provision to fortnightly. The home has links with the local community and is regularly visited by resident’s friends, relatives, chiropodist, district nurses and GPs. The hairdresser has recently retired and the home has been without a hairdresser for several weeks. Those residents with capacity are able to go out in to the community unsupervised whilst those with support needs are accompanied by staff. One resident said “I go to church every Sunday with my friends and go to church meetings and the Riverside Centre during the week”. A visitor was observed visiting their mother and reported that they called at the home several times a week and were always made very welcome. In discussion with staff they reported that residents are able to make choices about how they wish to spend their time, choice of meals, choice of clothing, how to send their money, time of awaking and retiring. On occasion the staff have had to support residents who do not wish to see certain visitors and exercised their right to choice. Several resident’s spoken with confirmed that they are able to make choices. Breakfasts are usually resident’s own choice. At lunch and teatime a menu choice is provided. A member of staff or the cook will ask residents for their preferred choice. The home does not display or provide a menu. Meals can be taken in resident’s own rooms or at the dining table situated in the ground floor lounge. The home has a large lounge with dining tables on the third floor but at present residents prefer to take their meals in the ground floor lounge. In discussion with the cook they reported that the home provides a varied menu based on residents food likes and dislikes. The home caters for two vegetarians. Fresh provisions are purchased twice weekly. Written feedback from four residents described the meals as excellent, hot and nice, generally good, and they are lovely. Several residents spoken with also stated the meals were very good. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 16 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 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: Information sent prior to the inspection visits indicated that the home have dealt with six complaints since the last inspection. Evidence of the complaints was recorded on a complaints sheet and details of the investigation and subsequent outcome were noted. All complaints are dealt with within 28 days. In discussion with several residents they reported that they felt listened to and would expect their complaints to be taken seriously. A visitor spoken with said “I have no complaints but would go directly to the manager if I did”. In discussion with two staff they demonstrated that they were aware of the home complaints procedures. The home has robust policies and procedures in place to safeguard the residents from adult abuse. The home also has a copy of the Isle of Wight Adult Protection Guidelines and displays the No Tolerance Poster and Leaflets in the reception area to inform residents and visitors. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 17 In discussion with the deputy they reported that they and two other senior staff had had adult abuse awareness training. There has been one adult protection referral since the last inspection, which was dealt with following procedures and the CSCI was informed. . Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 18 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 & 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for its stated purpose, it is accessible, safe and on the whole well maintained however there is room for improvements some areas. The resident’s benefit from living in a clean, safe pleasant, comfortable homely environment. EVIDENCE: On arriving at the home it was noted that the reception, hall and lounge had been trimmed with Christmas decorations and looked warm and inviting. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 19 A full tour of the premises was undertaken and it was noticed that the home is still experiencing settlement of the new extension which has considerable cracking within the plaster in many areas and this will need addressing as so as possible, as it is unsightly. There was also evidence of holes in some walls where work has been undertaken to find wiring and these have not been filled in and repainted and look unsightly. A residents’ bedroom had a loose electrical double socket, which was a potential health hazard. As the socket was coming away from the wall it was exposing plastering and a draft was blowing through from outside. The issue identified with regards to the decrease in natural light in a downstairs bedroom, at the last inspection has been resolved with the fitting of a second window. At the time of this inspection the room was vacant and was being used as a storeroom. The lounge/dining areas on both the ground and third floor are easily accessible to residents the home is fitted with a lift. Both areas are tastefully decorated and furnished to a high standard. A residents’ bedroom had had the en-suite extended and it was noted that the linoleum flooring was cracked and no longer fitted the expanse of the floor space. As a result the floorboards were exposed and appeared to be rotten and require replacement. The carpet in this bedroom was also torn and frayed in several areas and needs replacing. The work was not complete and plasterboard was exposed and looked unsightly, this requires plastering and decorating. The person who resides in the room said they would like the work doing as soon as possible. The garden has been repaired and developed, however in discussion with the manager and deputy they explained that it had not been used through the summer as they are waiting for railings to be erected to ensure residents safety. The outcome for the residents was that they sat out on the front balcony or asked to be taken to local tennis courts close by with nobody putting forward a complaint. It was noted that the radiator in the entrance to the lift was not covered and it was excessively hot with the area feeling like a sauna, two fire extinguishers were sited on the floor next to the radiator on noting this the manager moved them immediately. The older part of the home was very warm and felt uncomfortable to the inspector whilst the extension was a lot cooler. The manager reported that they had been experiencing difficulties with the central heating system and arrangements had been made for the system to be bled. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 20 All areas of the home were clean, reasonably safe and free from offensive odours except for two rooms in the extension, which had an strong odour. There was no obvious reason why these rooms should smell and it was believed by the inspector that the odours had come from the kitchen and was probably the smell of boiling vegetables, which can sometimes give off an offensive smell. There was a broken light fitting on a staircase and the bulb was exposed. Several of the first floor windows had not been fitted with window restrictors. Radiator covers in some bedrooms where not painted and looked unsightly. The carpets in the hall and staircases are stained and in discussion with the manager they reported that there are plans for these to be replaced. The Parker bath was out of commission and had been for 3-4 weeks, the outcome of this was that some residents have not been able to have a bath. In discussion with a senior member of staff they reported that those residents unable to have a bath have had a good overall strip- wash or shower. In discussion with the manager they reported that the bath is awaiting repairs and they are waiting for a part. The laundry is situated on the first floor and is fitted with an impermeable floor covering. The washing machine is of commercial size and has the appropriate setting for disinfecting soiled linen and clothing. There is a separate sluicing room, which is fitted with a wash hand basin. The home has an infection control policy and procedures. The home provides staff with protective aprons and gloves. All communal hand wash areas are fitted with liquid soap and disposable paper towels. The inspector observed the staff following the homes infection control procedures. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 21 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. Staff in the home are trained, skilled, and employed in sufficient numbers to fill the aims of the home and meet the changing needs of the residents. The home generally operates robust recruitment procedures however since the last inspection the manager has employed a number of staff without obtaining relevant documentation confirming that they are fit persons to work with vulnerable adults. EVIDENCE: The home currently employs 23 staff, which includes the manager, deputy manager, 3 senior carers, 12 carers 2 cooks, 2 cleaners, 1 handyman and a student. Staffing rosters indicated that there are sufficient numbers of staff on duty on all shifts. In written feedback from four residents, three felt satisfied that there are sufficient staff on duty whilst one felt that staff are often too busy to give them the time they need. In discussion with a senior member of staff they reported that they felt there were sufficient staff on duty at all times. Nine of the home’s 15 care staff have completed a National Vocational Qualification (NVQ) at level 2 or above with a further 2 care staff in the process of completing their NVQ qualification. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 22 Currently this means that 60 of the staff team hold an NVQ qualification, which should continue to rise to 73 in 2007 when the additional staff complete their courses. The inspector viewed three staff files of the most recently employed staff and found them to contain all the relevant documentation, Criminal Bureau Records, (CRB), Protection of Vulnerable Adults, (POVA) checks, 2 references and Identification. In discussion with the manager they reported that they had employed staff prior to the POVA being retuned and that these staff have always been shadowed during their induction. It was explained to the manager that this was a breach of the Amended Care Homes Regulations 2004 and they were genuinely shocked and explained that they must have misunderstood the new Regulations. As a result of this the residents safety and welfare had been temporarily compromised. In addition to the NVQ courses made available to the staff the company also offer staff the opportunity to attend core-training events, which includes Moving and Handling, Health and Safety, Fire Safety, Infection Control & Food Safety. Staff are also afforded the opportunity to attend courses that are not considered core to the business but are essential for the care and protection of the service users Parkinson study day, Medication Courses & Mental Health. In discussion with the manager they reported that they have focussed attention on training new staff, which had been employed from a home, which had closed, as these staff had not had any training. There was evidence that the home had obtained the Skills for Common Induction Standards. In discussion with the manager they reported that she and the deputy are going to complete the workbook and then intend to induct all staff using the new framework. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 23 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): 31,33,35 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is well run and managed. The management and administration of the home is based on openness and respect. The home does not have a reliable quality assurance system and needs to improve this. EVIDENCE: The manager is experienced and qualified to manage the home and has completed the NVQ level 4 in management and the Registered Managers Award (RMA). The manager is committed to self - development and has undertaken several training courses since the last inspection. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 24 In discussion with the manager they explained that they have been experiencing some health difficulties, which has impacted on their work and they were also tired following the stress of the building of the extension and feels that they are now just getting back on top of things. However the manager is going to address this and is considering delegating responsibilities to the deputy and senior staff. The home has an ex-member of staff who now works as a volunteer who has had the role of giving staff formal supervision. The manager explained that this person has been on long term sick and as a result staff have not received formal supervision for some considerable time. The manager also reported that there have not been any staff meetings for some considerable time. In respect of obtaining views from residents the manager and staff consult with them verbally on a day-to day basis, there are no formal systems in place to obtain views about the service from residents, relatives, health professionals and stakeholders. The home does not have an annual renewal programme, repairs, re-decoration and furniture replacement is done as required. The home prefers residents or their representatives to be responsible for the handling of their own finances. There are lockable facilities in all bedrooms. The manager is currently safe-keeping monies for one resident and lets them have access as required the resident signs a record log it was noted that the record did not have a balance of monies put in or taken out the manager agreed to do this in future. The home has policies and procedures in place for the health and safety of residents and staff. The staff team have undertaken mandatory training in the areas of health & safety. The home had a fire safety risk assessment and take advice fro a fire safety consultant. Fire alarm systems are checked weekly and records of tests are kept. Staff responsible for food handling, have had food hygiene training. The kitchen was clean and a cleaning roster was seen. Food is stored appropriately. The cooks are responsible for the recording of fridge and freezer temperatures and have failed to record temperatures since May 2006. Four items of food in the fridge had not been dated and labelled. Substances hazardous to health (COSSH) are kept in a lockable cupboard. A COSHH risk-assessment has been done. It was observed that the staff follow health & safety procedures Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 25 Evidence was seen that the home undertakes regular servicing of boilers and central heating systems. There was also evidence that electrical appliances and systems are maintained. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 1 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 3 x x 3 Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 (1) (b) (c) Requirement Timescale for action 31/03/07 2. OP7 3. OP7 4. OP9 5. OP19 You are required to ensure that all residents have a contract of the terms and conditions of the home. 15 (1) You are required to ensure that all residents have a care plan drawn up following their admission. Care plans must be reviewed monthly and where possible resident should be included in the reviewing process. 15 2 (a) You are required to review care (b) (d) plans monthly and unless it is impracticable to carry out consultation residents should be encouraged to be involved with the reviewing of their care plan. 13 (2) You are required to ensure that the homes self-administration of medication procedures are adhered to at all times. Regulation You must fit window restrictors 23 (2) (b) to all windows on and above the (d) first floor. You must remove and replace rotten floorboards and fit suitable floor covering to en- 18/12/06 31/03/07 18/12/06 31/03/07 Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 28 suite identified at inspection. A radiator cover must be fitted to the radiator on the ground floor lift entrance area. Repairs must be undertaken to fill in holes and repaint, damaged areas. You must replace worn and frayed carpets, which were highlighted at the inspection. The broken light fitting must be replaced. The electrical socket coming away from the wall must be repaired. Unpainted radiator covers must be painted. All repairs within the new build areas of the home must be undertaken to reduce disruption within the home. (This was a requirement at the last inspection 30/12/05) 6. OP30 19 (1) You are required not to take anyone into your employ until you have obtained written POVA first checks. You are required to recommence the formal supervision of staff to be at least 6 times a year. You are required to ensure that the cooks check fridge & freezer temperatures daily and record that this is being done. You must ensure that all left over food kept in the fridge is dated and labelled. 31/03/07 7. 8. OP36 18 (2) 13 (3) 31/03/07 31/03/07 OP38 Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 29 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. Refer to Standard OP12 Good Practice Recommendations Resident’s would benefit from the home displaying the weekly activities agenda and also the provision of information about what’s happening locally in the community. Downside House DS0000044123.V315953.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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