Inspection on 22/03/07 for The Downs House

This inspection was carried out on 22nd March 2007.

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

The Downs House 28/11/05

The Downs House 14/06/05

The Downs House 09/02/05

The Downs House 10/05/04

The Downs House 18/12/03

The Downs House 30/01/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Downs House Reservoir Lane Petersfield Hampshire GU32 2HX Lead Inspector Chris Woolf Key Unannounced Inspection 22nd March 2007 09:15 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 The Downs House DS0000011770.V332462.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. The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Downs House Address Reservoir Lane Petersfield Hampshire GU32 2HX 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) 01730 261474 Western Health Care Limited Mr Paul A Rogers Mrs Beryl Margery Rogers Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2007 Brief Description of the Service: The Downs House is a registered care home for up to thirty-seven older people, and is owned by Western Healthcare Limited. It is situated in a quiet road just outside of Petersfield with on site parking. The home provides a service based on ensuring the comfort, meeting the needs, and promoting quality of life for its residents. The current fees for the service at the time of the visit range from £480 to £610 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is info@downshouse.co.uk The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information for this report has been gained from a pre-inspection questionnaire completed by the home; one comment card submitted by a resident; and a visit to the home of 7.25 hours. The visit included speaking with the majority of residents, a variety of staff, the group manager, and 3 visitors (including one health care professional); observation of activities, a mealtime, medication administration, and the interaction between staff and residents; and inspection of a variety of records. What the service does well: What has improved since the last inspection? Since the last inspection the sluice has been completely re done; a new kitchen has been fitted; a new lift has been installed; the medication room has been re-sited; and there has been ongoing internal decoration. Training of staff has also improved. During the last year 14 staff have achieved their NVQ Level 2 in care and 7 have achieved Level 3 The Downs House DS0000011770.V332462.R01.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. The Downs House DS0000011770.V332462.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 The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, & 4. Standard 6 is not applicable for this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that their needs will be assessed prior to admission and that the home will only accept them as residents if they can meet these needs. This home does not offer the facility of intermediate care. EVIDENCE: A comprehensive assessment is made of all prospective residents; these assessments are carried out by the manager, sometimes accompanied by the group manager, and are supplemented by an initial assessment completed by the resident’s family. Most assessments are carried out at hospital, but some The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 9 prospective residents choose to visit the home and the assessment is carried out at this time. Some prospective residents visit the home for a respite stay, and often remain to become permanent residents. The first month of any stay at the home is classed as a trial period. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and cultural needs are recorded, and are met by the home supported by a multi-disciplinary health care team; their medication is handled appropriately; they are treated with dignity, and their privacy is respected. EVIDENCE: A comprehensive and holistic care plan is prepared for each resident, based on the pre-admission assessment, and then regularly reviewed. The home is about to purchase a new computerised care planning system. Care plans indicate the residents’ health, personal, and cultural needs; and visits to or from health care professionals are recorded. However, some staff need to be The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 11 reminded about the importance of documentation. The home maintains a falls file that includes details of each fall and the actions taken to prevent reoccurrence, and a chart is produced for the analysis of falls. The home maintains the residents health care needs with the support of health care professionals. One professional visitor commented, “The care is very good, they refer things onto us when needed”. A staff member commented, “Our priority is the care of the residents”. The homes policies and procedures for the recording, administration, storage, and disposal of medication are sound and enable an audit trail to take place. There is a homely remedies policy and G.P. approval for any homely medications used. Protocols are also in place for residents with swallowing difficulties. All staff who administer medication receive training, and competency checks are carried out regularly. A resident commented, “The staff give me my medication.” Residents are treated with dignity and their privacy is respected. Staff confirmed good practice in this respect and also said that they ‘encourage and promote independence’. A resident commented, “they always knock on my door”, and a visitor said, “they treat them with the utmost respect”. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead a full and active life; contact with their friends and family is encouraged; they have choices in all aspects of their daily life; and they receive a varied, wholesome and nutritious diet. EVIDENCE: The home endeavours to give residents a good quality of life. They organise a very comprehensive activities programme for residents with two or three activities taking place daily, including a weekly outing, and a happy hour each Sunday. A copy of the activities programme is displayed on each resident’s door and in the hallway. A service user comment card stated, ‘There are always activities arranged by the home’ and continued with the comment, ‘no compulsion is instigated ever. We have a weekly outing, visit to the local theatre & places of interest, there are parties for special occasions’. The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 13 Residents commented, “we have lots of activities”, “we went out for lunch yesterday”, “I go on the outings, we usually have tea or a meal, its laid on every Wednesday”, “One of the owners helps with some of the activities, she is a lovely lady”, and “I do the Yoga”. Staff commented, “I don’t think we could fit any more activities in”, and “They have a lot of variety”. Residents are encouraged to maintain contact with their friends and family. Visitors are always made welcome in the home and commented, “they make me welcome”, “they are always ready to listen and talk things through”, “I am always made welcome”, and “I bring the dogs in”. Residents commented, “visitors are made welcome”, “I went out for the whole day with my family last week”, and “visitors are welcomed and offered tea”. Residents are given choices in all aspects of their daily lives and are encouraged to maintain their independence. Staff commented, “they have choices in what they wear, where they want to sit, voting, activities, choice of supper etc, we try to encourage their independence as far as possible”. A resident commented, “I take Taxi’s into town”. The home provides a healthy and nutritious menu that meets the needs and wishes of the residents. Special diets are catered for as required. Pureed food is served in individual portions. Residents are able to choose where they eat although they are encouraged to enjoy the social occasion of eating in the dining room for their main meals. Residents commented, “Lunch is normally very good, I have breakfast in my room and could have cooked if I wanted it, we have coffee, tea, and after supper more tea plus we have a jug of water or squash in our rooms”, “The food is always good”, “The cooking is excellent good plain home cooking”, “The food is very good, most people have the same but we do have choices”, “I don’t really like casseroles but I can have something else if I want”. Staff comments about the food included, “Nice puddings”, “We can have a meal if we are on duty”, “Its always fresh food”, and “It’s a bit stodgy for my taste but the residents always enjoy it”. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their complaints will be listened to and investigated; and that they will be protected from abuse. EVIDENCE: The home has a clear complaints procedure and a copy is on display in the hallway. There have been no complaints since the last inspection. Records indicated that any complaints that are received are properly investigated and outcomes are recorded. Staff indicated that they would know how to handle a complaint made to them. A resident commented, “The manager always sorts everything”. Residents are protected from abuse. The home has clear policies on adult protection and prevention of abuse. All staff have been checked against the Protection of Vulnerable Adults register. Staff receive training in adult protection. Staff spoken to indicated that they know the protocols for dealing with abuse and also understand the whistleblowing policy. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and well-maintained home with rooms that meet their individual needs. EVIDENCE: The home is accessible and well maintained with a good parking area at the front and tidy and accessible gardens at the rear. Residents commented, “I walk around the gardens” and “We have nice grounds”. The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 16 Communal rooms include, a conservatory where some of the activities take place, a pleasant dining room, and 2 lounges. Residents’ bedrooms are personalised, and they are able to bring in some of their own belongings. Residents commented, “My room is nice”, “I’ve got lots of photo’s in my room”, “I have my own bits and pieces”, and “I’ve got my piano, TV. & C.D.” Visitors said, “She has got a nice room, but it’s a bit small”, and “She has some of her own furniture in the room”. On the day of the inspection visit the home clean and smelt fresh. A resident said, “Its always clean”, and visitors commented, “its not always as clean as it should be” and “No odours ever”. Adequate infection control procedures are in place. The laundry has been refurbished and it is fitted with a washing machine with the correct disinfection programme. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a sufficient number of properly recruited staff who are trained to meet their needs. EVIDENCE: Staffing levels in the home are sufficient to meet the needs of the residents and includes 2 waking and 1 sleep-in night staff and either the manager of the group manager on call at all times. The home currently has 72 of care staff with NVQ level 2 or above. During the past year 14 staff have taken NVQ 2, and 7 have done NVQ3. 7 staff are now going on to do an NVQ 2 in Nutrition & Wellbeing. Recruitment practices in the home are sound. No new member of staff is started in the home until satisfactory references have been received; an enhanced disclosure has been submitted to the Criminal Records Bureau, and The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 18 a satisfactory check of the Protection of Vulnerable Adults register has been received. All new members of staff receive a thorough induction to Skills for Care specification. Statutory training is regularly updated. All staff are trained in adult protection. Some staff have undertaken Dementia training and the remainder are booked to do the course later in the year. Resident comments about staff included, “the staff are very good, the old hands are the best”, and “the staff are very nice, very good, all very friendly”, and a visitor said, “The staff are very good”. Staff comments included, “I like the work and the people I work with”, “We are a good team”, and “There are some really nice people we work with”. The Downs House DS0000011770.V332462.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is run in their best interests; their financial interests are safeguarded; and the health and safety of staff and residents is protected. EVIDENCE: The home benefits from sound management. Currently the manager is Mrs. B. Rogers. An acting manager has now been appointed and is working towards her registration; and Mrs Rogers deals more with the activities side of things. The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 20 A group manager has also been appointed and was present on the day of the inspection site visit as the acting manager was on holiday. Residents said, “Mrs. R is a lovely lady”, and “xxx (acting manager) is very efficient and very friendly”. The home has developed their quality assurance programme. There are quarterly residents meetings and an annual meeting regarding activities. Questionnaires are circulated to various stakeholders, and an analysis of results if produced and investigated for common themes. The home has a suggestions box. Regular audits take place on a variety of subjects. The home has a development plan. Residents’ finances are controlled by the resident themselves or their families or powers of attorney. Small amounts of petty cash are maintained for residents and all records are satisfactory From observation of records and discussion with staff it is confirmed that formal staff supervisions are not taking place as regularly as needed. A recommendation is added that supervisions should increase to ensure that all care staff receive a minimum of 6 supervisions each year. The health, safety and welfare of staff and residents is protected. Mandatory training is regularly updated. There are hoists available to assist in moving and handling. COSHH storage is suitable. Kitchen hygiene is good. Safety certificates viewed were all in order. The home has up to date fire and health & safety policies. Accident recording is in order and an analysis of falls is produced and audited. The Downs House DS0000011770.V332462.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 3 3 X N/A 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 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 2 X 3 The Downs House DS0000011770.V332462.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. 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. 1. Refer to Standard OP36 Good Practice Recommendations Formal staff supervisions should increase to ensure that all care staff receive a minimum of 6 supervisions each year The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Downs House DS0000011770.V332462.R01.S.doc Version 5.2 Page 24 - 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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