Inspection on 16/08/05 for Downsvale

This inspection was carried out on 16th August 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 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 13/10/05

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 16 August 2005 10:00 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 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 H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Downsvale Address 6-8 Pixham Lane, Dorking, Surrey, RH4 1PT Telephone number Fax number Email 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 Amanda Jane Douglass CRH Care Home 35 Category(ies) of OP Old Age, 35 registration, with number TI Terminally Ill, 2 of places TI(E) Terminally Ill, 4 Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 35 service users in the older persons (OP) category, up to 4 may be in the category TI(E) (Terninally ill - 65 years and over). 2. Additionally, 2 service users in the category (TI) (Terminally ill - aged 50-65 years of age) may also be accommodated. Date of last inspection 9 August 2004 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. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted 3 hours. The Registered Manager, service users and staff assisted the inspector who was made very welcome during the inspection. Daily records, care plans, policies, the complaints procedure and accident records were viewed. The inspector spoke with service users and staff. The service users with whom I spoke were very complimentary about the home, and the staff said that the home was very friendly, the turnover of staff was very low and that the home was well organised. What the service does well: Service users looked well presented and said that they were happy in the home. One said that the food was very good and she was able to have visits from friends and family every day. A visitor said that the home was 5 Star and he couldn’t speak highly enough of the care received by his relative. The home has a relaxed and friendly atmosphere, and staff stated that they enjoyed working at Downsvale. The home employs an activities co-ordinator who arranges activities to suit the client group. A Saxophonist had been arranged to play on the 23rd of August, and old time music hall was to be held later in the month. Service users access the gardens if they so wish. One relative had written: ‘ I would like to thank everyone for the very kind care and help you gave to J during her stay with you. She was very happy and enjoyed the food, singing and kindness you gave her, especially the food!! Once again, many thanks.’ And another: ‘ Thank you to all the staff for the excellent care and affection showed to my mother during the 8 happy years she spent at Downsvale’ Service users live in a comfortable well - maintained home with large, accessible gardens. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 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 standard(s) EVIDENCE: Standards 3 and 6 were not assessed during this inspection. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 There is a clear and consistent care planning system in place that provides staff with the information they need to satisfactorily meet service users needs. The systems for administrating medication are satisfactorily. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans were evidenced to be clear, concise and updated as and when necessary. They included risk assessments, nutrition assessments, hygiene plans and aims and interventions when the service user is confused. Risk assessments included hazards, resulting in possible falls, and included strategies for the prevention of falls. Bed rail risk assessments were made and consent for bedrails evidenced. Care plans were signed by service users or their representatives. Service users chose their own General Practitioner and said that they are able to consult with them privately in their bedrooms. Eye sight tests are carried out regularly and service usersare referred to the hospital for hearing tests if necessary. Chiropody was also available. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 10 Service users stated that they were able to receive visits from friends and families in private, in their bedrooms. This was also the case when the General Practitioner visited. Staff were observed to knock on service users bedrooms before entering. Screens were provided in shared rooms to ensure privacy is not compromised when personal care is being given, or at any other time. The medication policy was viewed and the Medication Administration Records were examined and found to be in order. All medication was stored correctly and Controlled Drugs were recorded accurately. No service users self administer medication. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service users were observed to experience a full life with opportunities to take part in varied activities. Family and friends are able to visit and service users exercise choice and control over their lives. The meals in this home offer both choice and variety and cater for special diets. EVIDENCE: It was evidenced that service users were given opportunities for stimulation through leisure. A saxophonist had been booked for 23rd August, and an old time music hall was arranged for later on in the month. Care plans showed that the clergy visit regularly. Notification of future activities was displayed in the lounge. The home has a pet cat and it was observed that service users enjoyed the cat’s company. The manager said that occasionally she brings her puppy to the home for the service users to stroke. Service users said that they were able to have visitors at any time and one said that the home had arranged for her to have a candle lit dinner with another service user where they were served curry in her room. Service users said that there were no restrictions on having visitors. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 12 Service users spoke well of the food. They said that they have a choice of two meals at lunchtime and if the choice was not to their liking an alternative would be offered. Menus were examined and were varied, nutritious and balanced and catered for service users with special diets, such as diabetic or pureed food. Staff were observed to be professional, patient and unhurried when assisting service users to eat their meal, affording them dignity in this process. The meals were well presented. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a complaints system, however, the complaints procedure did not include timescales for the response to a complaint. Service users and staff were aware that they could inform the manager when they had a complaint. EVIDENCE: Service users and staff stated that they were aware that they could inform the manager if they had a complaint. The Complaints Policy and Procedure was viewed and did not contain timescales for response to a complaint. The telephone number of the Commission For Social Care Inspection was included in the Policy. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 The standard of the environment is high, providing service users with a safe, attractive and homely place to live. EVIDENCE: The grounds were observed to be tidy, accessible and safe to service users, allowing access to sunlight. It was evidenced that the building complied with the requirements of the local fire service and environmental health department. Service users bedrooms were homely and comfortable, with small items of personal belongings displayed in the rooms. One service user had a picture of herself as a young lady together with the family pet, displayed on her dressing table. Another had photographs of grandchildren decorating the walls. The bedrooms and communal areas were noted to be clean, comfortable and bright. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 15 Risk assessments of the environment were evidenced in care plans and reviewed regularly. Policies and procedures for infection control, including safe disposal of waste; dealing with spillages; provision of protective clothing and hand washing, were viewed. The home has a sluicing facility and sluicing disinfector. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Standards 27, 29 and 30 were not assessed during this inspection. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Service users receive good quality of care and said that they were very happy. They looked well cared for and smartly dressed. Care plans were comprehensive and included risk assessments. EVIDENCE: Service users looked smart and well cared for. They praised the staff and manager and said that the staff were kind and pleasant to them. Risk assessments of the environment were viewed and regularly updated. The home had held regular fire drills and fire safety training. Staff are trained in first aid, manual handling and food hygiene. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 18 Safety checks had been carried out on the passenger lift, water testing, PAT testing and the gas boiler and the Health and Safety At Work notice was displayed prominently. Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 3 Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 20 no 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 16.2 Regulation 2 Requirement The Complaints Policy and Procedure must include an assurance that complaints are responded to within a maximum of 28 days. Timescale for action 16/10/05 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 Good Practice Recommendations Downsvale H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 H58 s13316 Downsvale v230161 160805 stage 4.doc Version 1.30 Page 22 - 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. 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