Inspection on 13/10/05 for Downsvale

This inspection was carried out on 13th October 2005.

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

Downsvale 11/12/07

Downsvale 18/09/06

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 Catherine Campbell-Ace Unannounced Inspection 13th October 2005 10:00 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.V253032.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. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 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 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), Terminally ill (2), Terminally ill over 65 of places years of age (4) Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 35 service users in the older persons (OP) category, up to 4 may be in the category TI(E) (Terminally ill - 65 years and over) Additionally, 2 service users in the category (TI) (Terminally ill aged 50 - 65 years of age) may also be accommodated. 16th August 2005 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 ensuite 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. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted two and a quarter hours. The registered manager, service users and staff assisted the inspector who was made very welcome during the inspcetion. Staffing levels, service user’s choice, adult protection policies and procedures, assessment of service user’s needs and management and administration records were evidenced. The inspector had discussions with service users and staff. Service users said they were very happy living in the home, and the staff said that the training was excellent. What the service does well: What has improved since the last inspection? What they could do better: The home offers a high standard of care and support to service users. There were no requirements or recommendations from this inspection. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 6 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. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 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.V253032.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 A comprehensive assessment of needs is carried out before admission. EVIDENCE: It was evidenced that an assessment of needs was carried out before admission. This included skin condition, pressure area care, special equipment needed, for example walking frames or pressure mattresses and continence needs. The plan of care evidenced contained long term outcomes and risk assessment. No service user in this home is admitted for intermediate care. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 7,8,9 and 10 were assessed at the last inspection. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 10 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 EVIDENCE: It was evidenced that service users could choose their meals on a daily basis and choose activities suitable to their abilities. Activities included reminiscence and poetry, and making hats for Trafalgar Day. The records evidenced from the activities coordinator included outcomes, for example, enjoyment and interest from the activity. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 11 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 In this home the staff team are aware of the adult protection process, which ensures the safety and protection of service users. EVIDENCE: Policies and procedures in relation to the Protection of Vulnerable Adults were sampled. Two staff members spoken to stated that they have received appropriate training and were clear in their responses as to the action they would take if they witnessed any possible abuse. It was evidenced that the home’s policies showed that the service users or their families have access to their financial records, and that no valuables are stored in the home except after the death of the service user for an interim period until collection by the Next of Kin. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: Standards 19 and 26 were assessed at the last inspection. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 13 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): 27,29,30 The staffing levels in the home are adequate to meet service user’s needs. Appropriate recruitment practices are in place to ensure the safety and protection of service users. Staff are provided with appropriate training to carry out their duties competently. EVIDENCE: Staffing levels were evidenced and found to be satisfactory. 2 registered nurses and 4 carers were on duty the morning of the inspection. On the afternoon shift, there was rostered to be 1 RN and 3 carers on duty. Night shift comprised of 1 RN and 2 carers, 3 domestics on duty daily, plus 1 housekeeper, 1 laundry assistant, 1 kitchen assistant and in the evening, 2 supper assistants. The registered manager stated that when a function is booked, extra staff would be on duty. No member of staff in charge of the home is under 21 years of age. Three staff personnel files were evidenced and the required documents and CRB checks were in place, ensuring the protection of the service users. Staff training and development plans were sampled. Clear evidence was available that training and development takes place. One care staff member spoken to stated that the home provided ample training for her to do her job Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 14 well. Individual training files were evidenced, and showed that training had taken place in : Promotion of bladder and bowel continence, caring for people with strokes, principles of palliative care, mandatory training and day to day supervision. All training contained the objectives of training and whether the objectives had been achieved. Induction records were sampled and showed that staff received induction on the principles of care, safe working practices, the service user group and the worker role. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 15 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): 33,35 The home has an open management approach. Effective quality systems are implemented based on seeking the views of service users. In this home, service user’s financial interests are safeguarded. EVIDENCE: It was evidenced that the home has an annual business plan which included service user satisfaction, high staff moral and to be accredited as a learning environment for staff. The outcome of this business plan stated that the staff listen to service users, give high standards of care, involve staff in changed and commit staff to lifelong learning. The registered manager stated that the home self audits and regular audits are made through Regulation 26 visits. Questionnaires were sent to service users and relatives, but the response rate was poor. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 16 Policies and procedures were evidenced to be regularly updated and requirements identified in previous CSCI inspections had been actioned. The registered manager stated that it was the home’s policy not to handle service user’s financial affairs. Small amounts of money were held for service users and written transactions were evidenced. The registered manager also stated that secure facilities were provided for the safe keeping of money and valuables only after the death of a service user. The service user’s family would collect these valuables as soon as possible. Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 17 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 19 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 Downsvale DS0000013316.V253032.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!