Inspection on 18/09/06 for Downsvale

This inspection was carried out on 18th September 2006.

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 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 Lesley Garrett Key Unannounced Inspection 18th September 2006 08:00 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.V312035.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. Downsvale DS0000013316.V312035.R01.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 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.V312035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 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 Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was held over seven hours and commenced at 0900 and ending at 1600. Lesley Garrett lead inspector for the service carried out the site visit and the registered manager represented the establishment. The inspector carried out a tour of the premises and spoke with some service users and staff. She looked at some policies and procedures, care plans and employment records for some staff. The inspector would like to thank the service users, staff and manager of the home for their hospitality during this site visit. What the service does well: What has improved since the last inspection? What they could do better: Several requirements were made and these can be viewed at the end of the report. The requirements included the need for the manager to ensure that the Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 6 document that is used for pre-admission assessments is comprehensive and to evidence that care plans are generated form this form. The care plans are to be individual and demonstrates that care plans and risk assessments have been written for each service user. Privacy and dignity issues were raised during the inspection that included the homes practice of using communal toiletries not enabling service users to make choices and the use of disposable bibs when some of the service users are eating their meals in the hall/corridor of the home. There should be documented evidence that choice has been given. The home has received twelve complaints this year but the inspector could see no evidence that they had been investigated adequately and the what the outcomes were. The homes policy on safeguarding adults must be in line with Surrey Multi Agency Procedures. Some of the home’s radiators are not covered which could put service users at risk therefore risk assessments need to be in place if the home does not plan to cover them. Recruitment folders need to be checked to ensure that all paper work is in place as the folders the inspector sampled were found to be lacking in some of the required papers. There was no formal systems in place to review the quality of care in the home and this has also been made a requirement that the home also seeks the views of the service users. Manual handling practices must be reviewed by the homes manual handling co-ordinator. 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.V312035.R01.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.V312035.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. No serviced user moves into the home without having their needs assessed but the form being used should be expanded to allow a full assessment of needs. The home does not have intermediate care beds. EVIDENCE: The manager or the deputy will do all pre-admission assessments and the inspector sampled some of these. The inspector found that the assessment comprised of one sheet and this took into account their financial status. There was no evidence that this had been incorporated into the individual folders of the service users or that care plans were generated from a comprehensive assessment. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 9 A requirement will be made at the end of the report for the registered persons to devise a comprehensive pre-admission assessment form that demonstrates that care plans are generated from this assessment and is reviewed regularly. Downsvale DS0000013316.V312035.R01.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 at least once during a 12 month period. 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. Service users do not have individual plans of care and these are not updated on a regular basis. Some risk assessments are also not in place. The visiting professionals to the home meet Service users health care needs. No service user is responsible for their own medication and privacy and dignity is upheld. EVIDENCE: The inspector sampled the care plans for the service users and found these to be inadequate. There was no individual plan of care and all risk assessments and daily notes were contained in one folder. The inspector asked to see the individual care plans for the three service users that the inspector had identified and the manager printed them from the computer. The manager stated that these were reviewed every three months but there was no evidence of the review or that service users or their representatives had contributed to them. No service user had a nutritional risk assessment in Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 11 place. Any risk assessment that had been carried out was placed in one folder along with the daily notes. There will be a requirement at the end of the report for the care plans to be made individual for each service user with evidence of consultation and review every month. All risk assessments must be in place to include nutritional assessments. The manager stated that the home has good support from their general practitioner (G.P.). On the day of inspection the G.P. was on a routine visit to the home and this happens every week. The opticians visit annually and the chiropodist every eight weeks. The dentist will visit when called by the home and they also have access to the speech and language therapist and dietician. The tissue viability nurse will visit following a referral by the G.P. and the manager also stated that they have the support of palliative care nurses when it is needed. The medication system for the home will be assessed on a site visit from the Pharmacy Inspector for the Commission and that report will be available separately. The inspector saw the privacy and dignity policy and the manager stated that this topic is included in the induction for all new staff. Staff was observed to knock on doors before entering service users bedrooms. The inspector noted that at meal times some service users were wearing disposable bibs. The home has no dedicated dining room and foldaway tables are assembled in the lounge and the reception area of the second house. It is strongly recommended that the wishes of the service users be sought for the use of the disposable bibs as these could be seen not to promote the service users privacy and dignity. Downsvale DS0000013316.V312035.R01.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 at least once during a 12 month period. 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. The home has an activities organiser who provides activities, which match their expectation and needs. Family and friends are welcomed to the home whenever they want to visit but the service users have very little contact with the local community. Service users are allowed to exercise some control over their lives. The food at the home is of a good standard but the facilities for eating the meals are temporary. EVIDENCE: The home employs an activities organiser who works every afternoon. The manager stated that the organiser completes a profile for each service user but the inspector did not sample this document. Programmes are set and this is communicated to serviced users in a monthly newsletter, which the manager showed the inspector. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 13 The home has its own minibus therefore service users who are able can join in any trips that are arranged. Schools or any community groups only visit the home at Christmas the manager stated therefore this is an area that the activities organiser could explore to enable service users community contact as they wish. The inspector received CSCI ‘comment cards’ and some service users had commented about the provision of activities. One service user said that “most residents are incapable of taking part in any activities’ another said they cannot participate because they cannot walk. The manager stated that no service user manages their own finances. Service users are given choice about their daily lives including what they wish to wear, when they get up in the morning and when they go to bed. The service users can also choose where to eat their meals and the inspector observed some service users remaining in their rooms. During the tour of the building the inspector observed that the bathroom cupboards contained a variety of toiletries. The manager stated that this was for the use of all service users but this does not allow choice for them to pick their own toiletries and to keep them in their own bedroom therefore this will be a requirement at the end of the report. The inspector spoke with the chef who has been at the home for twenty years. She told the inspector that she has a four-week rota, which the inspector saw, and that service users are given a choice of food on the day. The inspector saw that some of the food in the fridge was not labelled and this will be a recommendation at the end of the report. Fridge and freezer temperatures are taken and recorded. Downsvale DS0000013316.V312035.R01.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and taken seriously but no outcomes following investigations are documented. Service users are protected from abuse. EVIDENCE: The manager stated that the home has a complaints policy, which is available in the service users bedroom and displayed in reception. A complaints log is kept at the home and the manager told the inspector that she had received twelve complaints this year. The manager had investigated all of the concerns but the outcomes have not been documented and there was no documentary evidence of letters having been written following completion of the concern. It will be a requirement at the end of the report that a record is kept of all concerns that are received by the home and outcomes are available to chart the outcome of all concerns. The home has a safeguarding adults procedure but this is not in line with the local authorities policy. This will be a requirement at the end of the report. The home has had no referrals under the safeguarding adults procedures and staff receive training in this area and it is also covered during induction for all new staff. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that needs to be modernised to meet the needs of service users who have increasing dependency. The home was clean and free from offensive odours. EVIDENCE: The home consists of two houses joined together by a walkway. The corridors are fairly narrow and can make manoeuvring a wheelchair difficult. The home has no dedicated dining room and some service users eat their meals in the reception/hall area. The registered persons need to review this situation as with increasing dependency of service users the dining room furniture is not suitable for their changing needs and can hinder the staff with regard to assistance with feeding. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 16 The inspector observed that not all radiators are covered and one service user had their bed and chair in front of one of these radiators. It will be a requirement that all radiators are reviewed to ensure that they are covered to protect the service users. The manager stated that there is a routine maintenance programme and decorating takes place on a regular basis. On the day of inspection the outside of the building was about to be decorated. The gardens are large and the manager stated that they are accessible to service users via the two side entrances. The home has recently built a wooden decked area and the inspector observed service users sitting there enjoying the sunshine. The home employs a laundry assistant who spoke with the inspector and had a good knowledge of infection control. The carers continue the washing during the afternoon when the assistant has left. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 17 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 28 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers of staff available and are in safe hands at all times. The home’s recruitment policy safeguards service users and staff is trained and competent to do their job. EVIDENCE: Staffing levels in the home remain consistent and rarely alter but the manager does not complete any dependency levels to assess the needs of the service users. The manager stated that she works, as a registered nurse therefore knows what is happening on the floor. Two registered nurses are on duty in the morning with one in the afternoon and one at night. Carers support the registered nurses. 50 of the care staff has the National Vocational Qualification at level 2 and the manager stated that some of the nurses are also assessors. There have been no new employees recently but the manager stated that trainees are not registered with the skills for care training programme. The inspector sampled three recruitment folders and found that one folder had no evidence of the required stamps from the Home Office in the passport and another had gaps in their employment history. It is a requirement that all employment folders since 2004 are checked to ensure that they comply with Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 18 schedule 2. The manager stated that training in the home takes place on a regular basis but she was unsure what the mandatory training was. The inspector saw the plan for the home and staff had received training in safeguarding adults, manual handling and fire training. Some staff still needs to do the basic food hygiene certificate. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has been in post for sixteen years and has a good knowledge of service users needs. Quality systems need to be put in place in the best interests of the service users. Service users financial interests are safeguarded. The health and safety of service users is protected in some area but some gaps were noted. EVIDENCE: The manager has been in post since 1990 and stated that she has regular training to update her knowledge, skills and competence. She told the Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 20 inspector that a lot of her shifts are as a registered nurse delivering personal care to the service users. The manager stated that she carried out a service user survey last year but obtained a poor response. The results were not fed back to service users and the home did not seek the views of other visiting professionals. It will be a requirement at the end of the report to establish a quality audit system for the home and for the results to be fed back to the service users and their relatives or representatives. The inspector left CSCI ’comment cards’ and have received a good response. No service users controls their own money but if they would like to purchase anything the home will buy it and this is then invoiced at the end of each month. The inspector observed two members of staff trying to move a service user from her chair into a wheelchair with incorrect manual handling techniques. The manager told the inspector that they have a manual handling co-ordinator and training has taken place. A requirement has been made for the arrangements for training to be reviewed to ensure the safety of the service users and staff. The inspector also witnessed the manager’s dog walk through the legs of a service user causing them to stumble. The manager stated that the dog visits the home everyday and the staff told the inspector that the service users enjoyed seeing the dog. The inspector met with the maintenance person who has been at the home for twenty years and he is responsible for all the fire alarm tests, water temperature checks and showed the inspector his records. The pre-inspection questionnaire detailed all health and safety checks that had been completed recently including fire alarm tests, fire drills, lift inspection and checks made on all hoists in the home. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 22 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. 1. Standard OP3 Regulation 14 Requirement 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. The registered persons shall ensure that each service user has an individual plan of care that also contains risk assessments and is reviewed monthly. The registered persons must ensure that service users are encouraged to make choices and decisions about the care they are to receive with regard to the toiletries and they are not to be communal. The registered persons must ensure that that all complaints investigated by the home contain the action that was taken to investigate and the conclusion be made available. The registered persons must ensure that the homes safeguarding adults policy is in line with Surrey Multi Agency DS0000013316.V312035.R01.S.doc Timescale for action 18/10/06 2. OP6 15 18/11/06 3. OP14 12(2) 18/10/06 4. OP16 22 18/10/06 5. OP18 13(6) 18/10/06 Downsvale Version 5.2 Page 23 6. OP25 13 7. OP29 19 & Schedule 2 8. OP33 24 9. OP38 13 procedures. The registered persons must ensure that all radiators and pipes are covered to ensure the safety of the service users The registered persons must ensure that all recruitment folders since 2004 are checked to make sure that all necessary recruitment checks have been made. The registered persons must ensure that they establish and maintain a system to review and improve the quality of care provided and ensure this is fed back to service users or representatives and to take into account other visiting professionals. The registered persons must ensure that suitable arrangements are in place to provide a safe system for moving and handling service users. 18/11/06 18/10/06 18/12/06 18/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP10 OP13 OP15 Good Practice Recommendations It is strongly recommended that the manager consult with the service users to review the use of disposable bibs in the home. It is strongly recommended that the provision for community contact for service users be explored as the service user wishes. It is strongly recommended that all food that is kept in the fridge is labelled and dated. Downsvale DS0000013316.V312035.R01.S.doc Version 5.2 Page 24 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.V312035.R01.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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