Care Home: The Downs House

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What the care home does well What has improved since the last inspection? The owners have employed a deputy manager at the home and another manager to take an overview of the two homes now being run by the organisation. This has ensured there is adequate management support to ensure the effective and efficient running of the services.The AQAA returned to us indicated that the registered persons are fully aware of the views and wishes of the people living at the home and other stakeholders. What the care home could do better: This report makes one recommendation in respect of the need to ensure that people`s plans of care and assessments are kept up to date and are fully reviewed, ensuring that people receive appropriate care and support. CARE HOMES FOR OLDER PEOPLE The Downs House Reservoir Lane Petersfield Hampshire GU32 2HX Lead Inspector Richard Slimm Key Unannounced Inspection 5th February 2008 9:00 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 The Downs House DS0000011770.V357018.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.V357018.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.V357018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 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 £560 to £720 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.V357018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience GOOD quality outcomes. This report detail the quality of the service provided at the Downs House and takes into account the evidence from information received about the home since the last inspection, which was carried out on the 22nd March 2007. The inspection took into account the home’s Annual Quality Assurance Assessment (AQAA), which was sent to the Commission for Social Care Inspection (CSCI) prior to the site visit to the home. Comment cards were received from two G.P.s and seven relatives/advocates of people living at the home. An expert by experience assisted us during this inspection, spending time with residents and listening to their direct feedback about the quality of the services being provided at the Downs House in a variety of areas. Their report is included within the main text of this report. Included in the inspection was an unannounced site visit to the home, which took place on the 5th February 2008. Evidence for this report was obtained from records seen at the home and a look around the service. The interaction between staff and service users was observed. It was also possible to meet and speak with 16 service users who live in the home, 2 members of the care staff, 2 district nurses providing health services to people living in the home and by speaking with the home’s registered manager, and two other managers. The home is registered to provide support for 37 older persons. At the time of the inspection visit there were 30 people living at the home. What the service does well: The two GP responses were positive and included the following comments – “I think this is an excellent home, my only comment is that when the main manager is not available, which is only rarely, the members of staff are not quite as informed, but still very helpful.” Comments from relatives included – “They are extremely patient and tolerant. All staff are kind.” The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 6 “We have nothing but praise for the staff,” “The Downs House is an exemplary example of how a care home should be run.” “The atmosphere is homely and it always smells clean and fresh and there are always lovely fresh flowers.” “They provide a cheerful and efficient home from home, with entertainment and social company that an older person living alone would not get.” “They supply a caring and friendly service and atmosphere.” “On the whole the support and care is very good.” “The manager is approachable and deals with any concerns effectively.” “They show compassion and care. Feelings are not disregarded just because residents are in their later years.” “They care for the whole person.” There is a wide choice of activities provided by the home with different activities available every day and weekly outings are arranged. People are made aware of activities and these are also advertised on the home’s notice board with the daily menus. People are involved in choosing the type, nature and frequency of activities via regular resident meetings. Residents said, “We have a happy hour every Sunday before lunch, when we get back from church.” One lady said, “They are very good at finding things to do”, and another said, “We like going out for pub lunches.” Someone mentioned ‘Sing-songs’ and the owner mentioned that there was a bus-ride for some of the residents on the following day. This was a regular event that was being planned into the other activities planned at the home. “We always have fish and chips every Friday.” “The food is good.” What has improved since the last inspection? The owners have employed a deputy manager at the home and another manager to take an overview of the two homes now being run by the organisation. This has ensured there is adequate management support to ensure the effective and efficient running of the services. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 7 The AQAA returned to us indicated that the registered persons are fully aware of the views and wishes of the people living at the home and other stakeholders. 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.V357018.R01.S.doc Version 5.2 Page 8 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.V357018.R01.S.doc Version 5.2 Page 9 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): We assessed standard 3. The home does not provide intermediate care services. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure people moving into the home have their needs assessed by a qualified person and are assured that these will be met. EVIDENCE: People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights as there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. The expert by experience reported that “One lady who had been at Downs House for a few years said, concerning her pre-assessment, ‘I filled in forms’ The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 10 and ‘they are careful about where they place the residents. You go downstairs if you are less mobile.” One gentleman said, “My son went into all the details and was quite happy for me to come here.” We case tracked 5 people. All case records showed clear assessment had been carried out for each person and their needs, wishes and aspirations had been identified in a person centred manner. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 11 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): We assessed standards 7,8 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are set out in an individual plan of care. These plans need to be kept under regular review. 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. EVIDENCE: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. Care plans also identify other issues such as wishes, feelings and aspirations, as identified in such areas as choice, likes, dislikes etc. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 12 Records of residents’ reviews and records that monitor outcomes for people were found to be out of date. The managers were aware of this shortfall and had recently employed a deputy manager who will be updating records and carrying out regular reviews with people. If residents take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. Feedback from a visiting district nurse confirmed that the home had worked hard to develop positive working relationships with the local community health care team, and this is beneficial to the people living in the home, and the effective delivery of local health care services. GP feedback was also positive as mentioned above. The expert by experience said “When I arrived, near the entrance there was a visiting physiotherapist helping a gentleman walk. All the residents whom I asked about doctors and medication had chosen or kept their doctor in Petersfield.” The Deputy Manager is the link between the professional visitors and the service users. Peoples’ right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. People interviewed confirmed that they were treated with dignity and respect at their home. Staff members were observed to promote and protect privacy in how they supported people, and were seen to knock on doors of bedrooms before entering. Locks were in place to all doors where privacy is to be expected. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 13 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): We assessed standards 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home identifies and then supports people to follow personal interests and activities. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 14 People are able to keep in touch with family, friends and representatives. People interviewed said they could receive their visitors at any reasonable hour, and in private if they wished. Visitors were observed during the inspection visit. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. Extract from the expert by experience report – “I noticed one visitor in a lady’s room after lunch. Other residents mentioned that they had visitors, sometimes to their rooms or in the lounge area. One resident said, ‘They are very good to visitors’. - “Residents were happily sitting and chatting in the reception rooms. From the Activities’ list displayed on every resident’s door, there seemed a wide range of activities on offer including trips into Petersfield for shopping once a week in one of the two buses, although one of them was not serviceable at the time of the Inspection. Residents can order taxis too if necessary. Two of the residents mentioned, ‘We have a happy hour every Sunday before lunch, when we get back from church.’ One lady said, ‘They are very good at finding things to do’, and another said, ‘We like going out for pub lunches.’ Someone mentioned ‘Sing-songs’ and the owner mentioned that there was a bus-ride for some of the residents on the following day. Another lady said she was consulted over the choice of her room and was able to move to a better room, albeit more expensive, on the ground floor sometime afterwards as it became vacant. The residents I spoke to were unsure of what a care-plan was but felt their needs were being attended to. For instance, the gentleman previously mentioned said that he gets up and goes to bed at the time he wants, and is helped by a carer, although sometimes he has to wait to be dressed. One lady said, “I really like to keep my independence.’ One more confused resident was using large playing-cards and building suits, but needed direction from a staff member. It was explained to me by the Manager that the Home was looking for therapies including the cards to help distract this resident. After lunch a lady came in to give Diversional Therapy which 11 of the residents attended. They were going to do a word game from a daily paper with the help of a large white wipe-board, talk about poetry and learn about Edward Lear and then try and create their own limericks. There was a hairdresser also in attendance during the day, but some residents prefer to go out to a local hairdresser’s. Nobody I spoke to had any other suggestions for activities. It was noted by residents that the piano near the dining room was never tuned. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 15 The lunch served on the day looked wholesome and well presented (chicken or pork casserole with broccoli and mashed potato, or a vegetarian option). The Deputy Manager spent some time patiently with the lady with dementia offering other choices of what she wanted to eat at lunchtime, when rejecting the casserole in front of her. The cook had made pancakes for pudding on the day of the visit, Shrove Tuesday. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 16 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): We assessed standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: There had been one complaint since the last inspection, this had been investigated and dealt within the stated timescales. If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. One resident had written to the manager recently about a staff member turning off her light. The manager is addressing this matter. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. The home has “Safeguarding adults and the prevention of abuse” policies and procedures in place to guide managers and staff in this respect. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 17 All staff members receive induction to the national standards that would cover safeguarding, and over 50 of staff are trained to NVQ level 2 with some having gone on to study to higher levels. The home adopts a thorough recruitment process that ensures that all staff are thoroughly vetted and all necessary checks are carried out to ensure they are suitable to work with vulnerable people. People’s legal rights are protected, including being able to vote in elections. Extract from expert by experience report – “The residents I spoke to were happy about the complaints’ procedure. One said that she was aware of the white box for complaints near the entrance hall, whereas one thought it was a mailing box for Mr and Mrs Rogers (the registered owners). I did mention to the Deputy Manager that it may be confusing having two notices on the white box, one saying ‘Complaints’ and one saying ‘Mail for Mr and Mrs Rogers’. She agreed with my point and said she would find somewhere else for the Rogers’ mail. One resident said that she could talk to Margaret (the care manager) and another said that she would talk to a carer if there was a problem. One lady said that ‘I am not sure who the person is to complain to, but can always speak to someone’. Another lady said, ‘If you have any difficulties, they’ll pull you aside and help you with it. Everyone is very kind. ’Some residents were aware of the residents’ meetings ‘every 3 or 6 months’ to discuss any problems or suggestions. A very contented lady added ‘Mrs Rogers is very kind, as she gets the drinks out at our meetings even after just having our coffee!’ The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 18 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): We assessed standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained, valuing environment. The home is clean, pleasant and hygienic. EVIDENCE: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 19 Extract from the expert by experience report – “During my visit three residents on the ground floor complained to me about the noise and some of the behaviours of a more confused resident. One said that it would put off people coming to the Home. The manager was aware that she needs to support all residents to have supportive surroundings. Residents confirmed that the home is always clean and fresh smelling. People external to the home but who are regular visitors also confirmed the home is cleaned to a good standard throughout. At the time of this visit the home was clean and tidy throughout, and there was evidence of busy domestic staff sorting out areas of cleaning. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 20 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): We assessed standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets Service users’ needs. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff members are trained and competent to do their jobs. EVIDENCE: The staff group includes 9 full time care staff and 14 part time, there are also 13 ancillary staff. The AQAA stated that 550 care hours were being provided with an additional 12 hours for non-care related tasks. The home employs an external activities coordinator/therapist. There was also an additional 200 staff hours provided all for the week prior to completing the form. There were 5 care staff, one cook, one general assistant, a trainee, the deputy and the care manager on duty at the time of the start of this unannounced visit. In addition to this the registered manager, and another senior manager were also available. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 21 From observations at the time of this unannounced site visit, and staff rotas, it was evident people have safe and appropriate support as there are enough competent staff on duty at all times. Over 50 of staff members are trained to the national benchmark of NVQ level 2. The people living in the home have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Peoples’ needs are met and they are cared for by staff that get the relevant training and support from their managers. Staff members confirmed that they received regular supervision with a manager. Extract from the expert by experience report - One resident mentioned that some carers were dissatisfied with the ‘management’ and that ‘the Manager was in her office most of the time not to notice’. Some complained that the carers were ‘very rushed in the morning’, one lady said ‘Pity the carers in the morning don’t have more time.’ None of those residents wanted to make a formal complaint about these comments. Two staff members were interviewed and it was evident the home is going through some significant changes as the registered persons now own and run two care homes and new managers are being employed that means the amount of contact with the owners may be decreasing to what it used to be. The staff members interviewed said that none of the issues that are arising with these changes are having an adverse effect on the people living in the home. Staff confirmed that if they have any problems on a day-to-day basis they feel able to deal with theses things quickly with the manager who is approachable. They also accepted that the owners and managers hold team meetings to provide a forum for discussing such issues that are not very well attended by staff. Residents interviewed spoke highly of care and management staff members, as well as the owners. Relative feedback was also positive about the staff group and the care manager. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 22 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): We assessed standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The home is run in the best interests of service users. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 23 EVIDENCE: People have confidence in the care home because it is led and managed appropriately. The current registered manager plans to hand over this role in due course to the care manager. We were advised an application would be made to register the care manager. Two staff members were interviewed and it was evident the home is going through some significant changes as the registered persons now own and run two care homes and new managers are being employed that means the amount of contact with the owners may be decreasing to what it used to be. The staff members interviewed said that none of the issues that are arising with these changes are having an adverse effect on the people living in the home. Staff confirmed that if they have any problems on a day-to-day basis they feel able to deal with theses things quickly with the manager who is approachable. They also accepted that the owners and managers hold team meetings to provide a forum for discussing such issues that are not very well attended by staff. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The last residents meeting took place on the 18/1/08 and covered 16 different areas including meal times, menus, key worker system, new staff, activities and new developments such as the new picture gallery. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The home offers a service to all residents, their relative /estates that people can have access to money when ever required and this can be billed at a later point. This ensures people always have access to money and also cuts down the chance of money being lost or going missing. The environment is safe for people and staff because appropriate health and safety practices are carried out. The home’s AQAA declared that all systems and equipment is tested and maintained in line with the manufacturers recommendations. The home has comprehensive operational policies and procedures, many promoting health and safety and best practice guidance for staff members. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. People living at the home get the right care because the staff are supervised and supported by their managers. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 24 Extract from expert by experience report – “Everyone I saw looked happy and well-groomed. There was a calm atmosphere about the Home. Staff spoke to residents with respect and several residents mentioned how lovely Mrs Rogers (one of the owners) was. One very contented lady I met was having respite care and joked that she had been there before and would be returning no doubt in the future and one day for good. Just before I left, one of the residents said, ‘We seem to all go together. I love it to bits’, which was a fitting end to my enjoyable visit.” The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 25 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 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 26 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 OP7 OP3 Good Practice Recommendations The registered person should ensure that care plans and assessments of need are reviewed on a monthly basis and record the outcomes of the people being supported. Monthly review notes should be recorded and care plans updated if needs have changed. This process should then link into the annual review of care carried out at the home with the residents. The Downs House DS0000011770.V357018.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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.V357018.R01.S.doc Version 5.2 Page 28 - 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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