Inspection on 11/12/07 for Downsvale

This inspection was carried out on 11th December 2007.

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

Downsvale 18/09/06

Downsvale 13/10/05

Downsvale 16/08/05

Downsvale 09/08/04

Downsvale 27/04/04

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 Downsvale 6 - 8 Pixham Lane Dorking Surrey RH4 1PT Lead Inspector Sarah MacLennan Unannounced Inspection 11th December 2007 09:45 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 Downsvale DS0000013316.V348516.R02.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. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downsvale Address 6 - 8 Pixham Lane Dorking Surrey RH4 1PT 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) 01306 887652 brianmathews@btconnect.com Dr B H Mathews Miss A Douglass, Mrs P Mathews Miss Amanda Jane Douglass Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 4 service users who are in need of palliative care may be accommodated at any one time 2 service users who are in need of palliative care aged between 50 and 65 years may also be accommodated 18th September 2006 Date of last inspection Brief Description of the Service: Downsvale is a Registered Nursing Home caring for up to 35 older persons. The home consists of two large detached houses joined by a covering link way. It is set within a large garden in a residential road close to the town centre of Dorking. Some bedrooms are en-suite and there are ample communal bathrooms and shower facilities in addition. There are also many WC facilities, thus exceeding the expected standards in this area. The price range of the rooms are £685 - £725 per week. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit formed part of the key inspection process and took place over 5½ hours commencing at 09:45 and ending at 15:15. Sarah MacLennan, Regulation Inspector, carried out the visit. The manager was present throughout the inspection. As part of the inspection process a tour of the premises took place. Various written records were examined, including three care plans and service user assessments, four staff personnel files, samples of staff training records, the complaints record and samples of the homes maintenance records. The inspector spoke to a number of service users and some staff members. Some of the comments made to the inspector are quoted within this report. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the visit. What the service does well: What has improved since the last inspection? The manager stated that all radiators within the home have been risk assessed. Radiators deemed to be a risk to service users have been covered to ensure the safety of service users. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 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 Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users had been assessed prior to admission to the home, however this assessment was not comprehensive. The home does not offer intermediate care. EVIDENCE: The inspector was advised that the registered manager or the deputy carry out a pre-admission assessment on all prospective service users. Three service user care plans were seen and had pre-admission needs assessments completed. Two of the assessments seen did not contain a date and the third had not been fully completed. This pre-admission assessment was a single sheet of paper and did not cover all elements of physical, mental, Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 9 and social needs. The requirement made at the previous inspection has been repeated. Service users and relatives spoken to felt they had received enough information prior to moving to the home. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users care plans are not person specific and there was no evidence of action taken following identified risks; however all service users spoken to stated that they were happy with the care they received. EVIDENCE: The service user care plans and files were randomly sampled; three service user care plans, risk assessments and daily statements were looked at in detail. The care plans did not contain specific instructions to staff and were not personalised to the service users. The requirement made at the previous inspection has been repeated. One service users care plan stated that she should be toileted as required, yet her continence risk assessment said she required no intervention. Two of the pressure sore risk assessments had identified service users as being at risk; however there was no evidence of any action being taken. The registered manager stated that the home did not Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 11 have any incidence of pressure sores and that pressure relieving aids were available within the home. The service users daily statements contained several entries ‘care as plan’ this did not provide details of the service users 24hr day. Service users and relatives spoken with were complimentary regarding the care that they received in the home. Comments included; ‘I’m very happy here’ and ‘it’s good here’. Service users were registered with a local GP and had access to other health care services including optician, dentist, chiropody, physiotherapy, occupational therapy, dietician and clinical nurse specialists from Princess Alice and St Catherines Hospices. The medication system for the home will be assessed on a site visit from the Pharmacy Inspector for the Commission; the report will be available separately. Conversation with staff, relatives and service users evidenced that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. When asked if they received the support they required service user comments included ‘yes, the staff are very good’. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities and food are suitable for the needs of the service users. EVIDENCE: From examination of the service user records and discussion with relatives, staff and service users it was apparent that service users are encouraged and enabled to live a full life and to participate in age related activities such as board games, quizzes, arts and crafts and reminiscence. Service users spoken to gave examples of activities they had recently enjoyed and stated that the provision of activities was suitable for their needs. Comments from service users included ‘I am very happy’. The inspector was informed that the home has a minibus and outings are arranged approximately six times a year. The home employs an activities organiser who works every afternoon. Pets are encouraged to visit the home, the home has two cats and the managers’ dog visits regularly. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 13 The home has links with various religious establishments in the local community. Church of England and Catholic services take place regularly. Due to the needs of the current service users, representatives of other denominations do not currently visit the home. Relatives spoken to stated that the staff always welcomed them in the home. All service users and relatives spoken to stated that they were happy with the food provision within the home. Service users were observed to eat lunch during the inspection. The home has no dedicated dining room and some service users eat their meals in the reception / hall area; whilst this is not ideal, all service users spoken with were happy with this arrangement. The menu was on a four weekly rota and alternatives were available on request. No cultural diets are currently provided, but could be upon request. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural groups. Conversation with staff, relatives and service users evidenced that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. Staff were observed to treat the service users with respect and care was provided in an unobtrusive and dignified manner. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a simple and accessible complaints procedure; service users stated that they felt safe at the home. EVIDENCE: The home had a simple and accessible complaints procedure. A copy of the complaints procedure is in a folder in all the rooms. Service users spoken to during the inspection were aware of who to speak to should they have any complaints and felt confident that they would be listened to. The homes complaints and concerns log was seen at inspection. It was positive to note that all complaints and minor concerns are appropriately investigated and recorded. There had been 11 minor concerns / complaints since the last inspection. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. One service users spoken to said ‘everything is very good here’. The home had a basic adult protection policy. This policy had recently been updated, to state that suspicions or allegations of abuse should not be investigated by the home, in line with the Surrey Multi-Agency policy. Discussion took place regarding the basic nature of the homes policy; the manager stated that she would review it in accordance with the Department of Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 15 Health guidance ‘No Secrets’. Staff spoken to were aware of their whistle blowing responsibilities. Staff had received training in the protection of vulnerable adults. All service users spoken with stated that they felt safe at the home. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was found to be clean, tidy and suitable in layout for its purpose. EVIDENCE: The inspector toured areas of the home. The home consists of two houses joined together by a walkway. The corridors are fairly narrow and could potentially make manoeuvring a wheelchair difficult. The home has no dedicated dining room and some service users eat their meals in the reception / hall area; whilst this is not ideal, all service users spoken with were happy with this arrangement. Service users able to access all areas of the home and grounds. The home was suitable for the needs of the service users. The décor was domestic in nature and general standards of maintenance were satisfactory. It was seen Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 17 to be clean, tidy and free from offensive odours. Service users spoken to stated that the home is always clean, other service user comments included ‘I have a nice room’. The manager stated that all radiators within the home have been risk assessed. Radiators deemed to be a risk to service users have been covered to ensure the safety of service users. The gardens are large and the manager stated that they are accessible to service users via the two side entrances. There was a large wooden deck area that the service users were able to enjoy. One service user stated that they ‘loved to walk about in the garden’. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the service users. EVIDENCE: Discussion with the manager, staff and service users demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living in the home. The inspector was informed that the home maintains staffing number of two trained nurses and four carers in the morning, one trained nurse and three carers during the afternoon and one trained nurse and two carers at night, when the home is at full occupancy. The staffing levels were reduced at the time of the inspection, as there were only 26 service users. The home had adequate ancillary staff on duty at the time of the inspection. Four staff files were seen during the visit and found to contain the required information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 19 The staff training records were randomly sampled, they evidenced that staff had received mandatory training in infection control, basic food hygiene, basic life support, fire safety, manual handling and protection of vulnerable adults. Staff had also received service user specific training that included dementia care, pain management and wound care. Service users and relatives spoken with were complementary about the staff at the home. Comments included ‘the staff are lovely’ ‘the manager and the staff are very helpful’ and ‘the staff are very good’. All interactions observed between the staff and service users were caring and respectful. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from the management approach at the home, which provided an open, positive and inclusive atmosphere. EVIDENCE: The registered manager, Amanda Douglass, is a registered nurse who has achieved her registered managers award. She has been in post since 1990 and stated that she has regular training to update her knowledge, skills and competence. She demonstrated a good knowledge and awareness of the service users needs and service users were seen to interact readily with her. The manager told the inspector that a lot of her shifts are as a registered nurse delivering personal care to the service users. All service users and relatives Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 21 spoken to spoke very highly of her and an open and inclusive atmosphere was evident within the home. All staff and service users appeared happy, contented and relaxed with the inspection process. The atmosphere within the home during the inspection was lively and cheerful. The registered manager stated that various quality audit systems were in place to ensure the staff, service users and their relatives had a forum for airing their views. These included staff meetings, service user and relative surveys and ‘job chats’. The minutes of these were randomly sampled. All service users spoken to felt that their views were listened to and taken seriously. The manager consults regularly with the service users on a one to one basis, but there was no documentary evidence to support this. Procedures were in place to safeguard the financial interests of service users. No staff members are appointees for service users. The registered manager is aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were in place; samples of which were seen. Staff were observed to be following appropriate health and safety practices as they went about their work. Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 22 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement Timescale for action 18/10/06 2. OP6 15 The registered persons shall ensure that the form that is used for pre-admission assessments is comprehensive and is kept under review and care plans are generated from this. This is the second time this requirement has been made. The registered persons shall 18/11/06 ensure that each service user has an individual plan of care that also contains risk assessments and is reviewed monthly. This is the second time this requirement has been made. 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 Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Downsvale DS0000013316.V348516.R02.S.doc Version 5.2 Page 25 - 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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