Inspection on 07/04/08 for John Collin House

This is the latest available inspection report for this service, carried out on 7th April 2008.

CSCI found this care home to be providing an Good service.

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

John Collin House 14/11/06

John Collin House 13/04/06

John Collin House 27/09/05

John Collin House 19/04/05

John Collin House 25/10/04

John Collin House 07/02/04

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Henry Nihill House

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Edenvale

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Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE John Collin House Sutton Lane Hounslow Middlesex TW3 3BB Lead Inspector Ms Jane Collisson Key Unannounced Inspection 7th April 2008 11:00 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 John Collin House DS0000022891.V361723.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. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Collin House Address Sutton Lane Hounslow Middlesex TW3 3BB 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) 0208 572 2684 0208 572 2685 Svetlana.Robson@servitehouses.org.uk Servite Houses Svetlana Robson Care Home 26 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (0) John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 9/05/2006, four named service users (1 Male, 3 Female) with a Mental Disorder can be accommodated within the home. 17th April 2007 Date of last inspection Brief Description of the Service: John Collin House is a detached purpose-built home situated in a residential area of Hounslow. The London Borough of Hounslow leases it to Servite Houses, who manage the home. It is situated between Hounslow Town Centre and Hounslow West, where there are shopping facilities and underground stations. There are bus routes passing close by. The home is registered for twenty six, who can be older people, or people with learning disabilities, either over or under 65 years of age. There are four separate units, two for six people and two for seven people. One unit was previously designated as being for six people with learning disabilities but is no longer used for this purpose. Each unit has its own lounge/dining room with kitchenette area. A larger multi-purpose lounge, on the ground floor, is used as the main dining room and for social activities and functions. There are twenty two single bedrooms and two double bedrooms. The double rooms and one single room are en-suite. The offices, kitchen and laundry room are located on the ground floor. The sleeping in room is on the first floor. There is a large garden around the home, with seating areas and a greenhouse. There is parking to the front of the home. The staff team consists of a Registered Manager, an Assistant Manager, three Senior Support Workers, a team of day and night Support Workers, domestic and laundry workers. There are two members of staff on waking night duty, one of whom is a senior support worker. The provision of meals is contracted to a catering company, who employ the kitchen staff. The current fees for the home are £565.14 a week. All of the placements are made through the London Borough of Hounslow. John Collin House DS0000022891.V361723.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 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place on the 4th April 2008 from 11am to 4.00pm. The Manager and Assistant Manager were present. We observed the activities taking place in main lounge and toured the home with the Manager. We met and spoke with most of the twenty two people living in the home during the course of the inspection. Additional visits took place on the 9th and 11th April to examine further records and to meet more people living in the home. Two visitors were met in the course of the inspection, which took a total of eleven hours. The home had twenty people living permanently in the home, and there was one person staying for a respite visit. There are five vacancies. Some people were in their bedrooms or the lounges, others were seen participating in the activities on two days, which included gentle exercises and a sing-a-long. The foyer has seating and a number of people regularly enjoy sitting in the area, talking to staff and visitors. The regular programme of activities has been welcomed by the people living in the home. We noted a number of improvements when touring the home. These included the new kitchenette cupboard doors and worktops. Bathrooms and corridors have been painted and a number of areas were being measured for new carpets on the first day of the inspection. The Manager confirmed, shortly after the last visit, that the laying of the carpets had commenced. A great improvement has been the changes to the lighting in three of the corridors, which had previously been quite dark. The fourth corridor is due to be done. The front of the home has been tidied, with seating areas now provided and containers of bright spring flowers enhancing the general appearance. Action is being taken to make the grounds more secure. Overall, the home’s environment has significantly improved. We examined records which included care planning files, medication administration, maintenance and complaints. Lunch was observed in the main dining room on two days and we sampled the food. The people living in the home were complimentary about the meals. Since the last inspection, the Manager has been registered with the Commission for Social Care Inspection and there is an Assistant Manager in post. The support worker vacancies have been recently been filled. The general improvements we noted were also commented on by the visitors and in a letter from a relative. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 6 There were no specific cultural needs identified or being catered for with the exception of culturally appropriate meals being provided for one person. Mandatory training for equality and diversity training was held in 2007 and will be held for those recruited in 2008. At the last inspection in April 2007, there were sixteen requirements, which have now been met. Four have been made at this inspection. The Manager had recognised at the last inspection that there were shortfalls which needed to be addressed and she had made great efforts to ensure that the Care Home Regulations 2001 and National Minimum Standards are met. The Manager had completed the Commission for Social Care Inspection’s Annual Quality Assurance Assessment, which provided details of how the home is operated and the improvements that the home has made, or intends to make. This was completed in October 2007 and the majority of the proposals had been completed. The Assessment also provided statistical information regarding the people living in the home, the staff and maintenance. What the service does well: What has improved since the last inspection? What they could do better: John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 7 Whilst most health needs were recorded, those which may require regular monitoring did not have all of the information available. The Manager must ensure there is full guidance and training in place to support the person and the staff where specific needs are identified. Risk assessments have been carried out for a range of potential hazards. However, it needs to be ensured that the new risk assessments, currently being introduced for manual handling, contain the detail of the previous assessments and help to safeguard people and the staff who support them. They need to be detailed, dated and regularly reviewed. The fire risk assessment had been completed but needed more information where there are specific risks, such as people smoking in their bedrooms, with details of the precautions in place to reduce the risks to themselves and others. 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. John Collin House DS0000022891.V361723.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 John Collin House DS0000022891.V361723.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): 1, 3 (6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The documentation to support people to make a decision about moving to the home is up-to-date. People have information on the terms and conditions of the home. People are not admitted without a full assessment being obtained. EVIDENCE: Since the last inspection, the Service Users Guide and the Statement of Purpose have been updated. The Manager was in the process of providing new copies to the people living in the home. However, the home’s categories of registration were in need of changing to reflect the services that the home is now providing and discussions were in progress between the Commission for Social Care Inspection and the Manager. In addition to people in the home who are within the category of old age, there are also people with dementia, learning disabilities and mental disorders. When the categories are finally decided, the Statement of Purpose and Service Users Guide will need to be John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 10 updated to show how the needs of the people are being met by the staffing levels, training, facilities and activities. The Manager provided us with copies of the Licence Agreement and terms and conditions. The completed copies are provided to the people living in the home. However, the actual finances are dealt with by the Local Authority, who are the block purchasers of the places in the home, so the home does not have information about people’s individual finances. Some changes of bedroom have been made, with the agreement of the people involved. The Manager confirmed that she always receives assessments from the Local Authority, the London Borough of Hounslow, before anyone is considered for admission. We looked at samples in the files, which were comprehensive. She does not use special assessment documentation, but uses the care plan format to decide how the needs of the person can be met. Social Services have been involved in looking for new placements where alternative accommodation has been identified as being a need for some residents. The home does not have an Intermediate Care unit, so this key standard could not be assessed. John Collin House DS0000022891.V361723.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): 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. Care plans are person centred and easy to understand. People are consulted about the service on a regular basis. People are treated in an appropriate manner and individual choices are respected. There are risk management strategies in place. People have access to community health care facilities. There is better compliance with medication procedures and systems in place to try and minimise errors. EVIDENCE: We looked at a total of seven care plans in respect of people living in each of the four units. Improvements have been made since the last inspection to the care plans and the associated documentation. However, the Manager said that further changes are to be made so that there is space for the people, or their representatives, to be able to sign their agreement. The care plans were much easier to access than previously and the files contained daily notes, recordings of meals taken and health related records. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 12 We looked specifically to see if the health needs of the people living in the home were being recorded and monitored, as inaccurate information had been seen at the last inspection. Again, we noted much improved records. However, there were two instances where more information was required to ensure that the health diagnosis, proposed treatment, medication and reviews were all in place. This included the information on a person noted previously to have epilepsy. Better management of the people with diabetes has been put in place with regular checks on blood sugar levels now being undertaken. All of the plans seen had risk assessments. New manual handling assessments have been put into place, but we noted that these did not always provide the information shown on the previous assessments, which were still in use. The previous assessments had details of the specific moving and handling techniques required for each person and should be retained unless the new risk assessments are improved. It was also noted by the Provider’s representative, carrying out the Regulation 26 monthly visit, that the risk assessments needed reviewing and dating. Risk management plans are in place for a variety of identified risks for each individual person. A small number of people are able to access the community independently and the Manager has tried to ensure that their movements are known, so that they are not put at risk. The Manager said that the home has now accessed regular chiropody visits again, after a long period where there were difficulties, and details of visits were seen in the health records. We checked the medication, which is stored in each of the units. A 28 day blistered system is used for the majority of the medication. The non-blistered medication was checked and was all found to be satisfactory. A list is held of each of the non-blistered medications and the numbers of tablets which should be in stock is checked daily. We did find a concern with the medication brought in for a person on respite, where the stock could not be checked as the numbers of tablets had not been recorded when brought into the home. Staff said that this is not the normal practice and had been the result of a lack of a Medication Administration Record sheet being available. Some medication errors have been made which are picked up quickly as the medication administration is checked daily. The Manager was taking appropriate action to deal with staff known to have made mistakes. Senior staff, and those who administer medication, have had advanced training. A refresher course was due in May from the pharmacy. We found that the people living in the home were positive about the staff and the services the home provides. People were observed to be spoken to appropriately and a good rapport was noted between some residents and staff members. Two people remarked how good the staff were to them. We met two visitors who were pleased with the improvements to the home. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 13 There are two double rooms in the home, one of which was being shared, and the people have agreed to continue sharing even though offered a single room. As this room is en suite, there are no issues with regard to privacy. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. There is a varied programme of activities to enjoy. People are encouraged to exercise choice about their daily lives. Friends and family are free to visit as people wish. Meals are balanced and provide a varied diet. Use of made of all the communal areas to ensure that residents have a choice about where they wish to spend their time. EVIDENCE: During the last few months, an Activities Organiser has been employed and a regular programme of activities is advertised and takes place. We observed these on two of the visits, where people were taking part in gentle exercises and a sing-along. These are held in the large ground floor lounge, which is now also used as the main dining room. Those people who do not wish to join in with the activities, and prefer to stay in the units or their rooms, are free to do so. However, the majority of people seemed to enjoy the morning programme of activities and joining other people in the lounge. One said that the exercises “are good for you” and people had the chance to relax afterwards, with a quiet “sing-a-long”. The unit lounges have televisions and there is a large screen television in the main lounge. The John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 15 Registered Manager has introduced “fruit fun” as part of the daily routine, where fresh fruit is prepared and offered to encourage a healthier diet. A small group of people enjoy sitting in the foyer of the home, talking with the visitors, staff and other residents. A small number of people are able to go out independently. Visitors are welcome to the home and two, who visit regularly, were seen on this inspection. Regular outings are planned. The outstanding requirement, for the home to have records to determine if the diet provided to people is satisfactory, is now being met. This was to demonstrate that people with special dietary requirements, such as those with diabetes, are shown to have a diet to suit their needs and promote good health. Information is provided in the care plans on the dietary needs of each person. Since the last inspection, the catering company that manages the kitchen has changed. The menus for four weeks are displayed and two lunchtime meals were observed. It would be a useful addition if the menus were more accessible, to enable people to know the choices. The main meals were previously served in the unit kitchenettes, which are quite small. The staff said that the use of the larger dining room had met with a mixed reception but people had the opportunity to eat in the units, or their rooms, if they preferrred to do so. The cook and the assistant cook were met. The cook confirmed that, although the menus are the same in each Servite home, some changes can be made where the people living in the home do not enjoy a particular meal. There are two choices each day of main course and additional choices, such as a salad or omelette, are also available. The general opinion of the people living in the home was that the food was “very good”. A more extensive range of diabetic desserts is now available although these are not advertised. The Local Authority’s Environmental Health Officer had visited the home the week before this inspection. The report was not yet available but the cook and Manager confirmed that it had been satisfactory in all respects. There have been problems with the dishwasher. We were informed that this is to do with the water supply and age of the building, rather than faulty equipment. On the second day of the inspection, the lunch being served was roast beef, with an alternative of vegetable cottage pie, which was sampled. The dessert was bananas and custard. We spoke to people about the meals and they were generally very positive, saying “I enjoy them” and “the meals are very good”. One person felt that there could have been more sauces on the food but acknowledged that other people did not necessarily like them. In order to encourage the uptake of fruit, it is served at the activities sessions. John Collin House DS0000022891.V361723.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an open culture which allows for people to express their views. The complaints procedures are supplied to everyone in the home. Appropriate reporting is carried out when safeguarding adults issues are raised. Staff have safeguarding adults training. EVIDENCE: We examined the complaints log and found that sixteen complaints have been recorded since the last inspection. These included concerns about the standard of toilet paper to complaints about the behaviour of staff and other residents. People spoken to were confident about raising complaints and were generally positive about making their concerns known. Regular meetings are held for people to be able to express their views. One anonymous complaint was being investigated by a senior Servite manager and a previous one has been taken to the Local Authority’s safeguarding adults department. This was found not to be substantiated. It was recommended to the Manager that further discussions take place on whistle blowing with the staff team to ensure that, if there are concerns, they are taken through the appropriate channels. There had been another safeguarding adults issue raised via the London Borough of Hounslow’s safeguarding adults department, which resulted in an agency staff member not being re-employed. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 17 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, 21, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now provides a more comfortable, bright and homely environment, suitable for the people who live there. The layout of the home allows for people to live in smaller units, but also has the communal areas where activities can be enjoyed. EVIDENCE: A number of areas of the home were in need of improvement and had been so for a number of inspections. Work was underway to provide new carpets in some corridors and communal areas. The four kitchenettes have had their cupboards and worktops replaced. The cookers, previously in each area, have been removed and all meals are cooked in the main kitchen. There is limited space in some of the small lounges for dining and most people now use the large lounge, which makes a pleasant and spacious dining room. People who wish to eat elsewhere, or by themselves, are able to do so. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 18 Other changes include the repainting of the bathrooms. These had been difficult to clean because of the stained surfaces. In addition to being painted, efforts have been made to make them more homely. All round the home, the Manager has added pictures, ornaments and flowers to improve the environment. The garden has been improved with plants, seating areas and was neat and tidy. We met one of the residents who enjoys helping in the garden and watering the plants. The greenhouse is in need of some refurbishment but the Manager hopes to bring it back into use. Most of the bedrooms were seen during this inspection and we found that they have been personalised to suit the person’s individual needs and people agreed that they have been able to bring in some of their own items. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 19 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. The recruitment of a more permanent staff team is supporting the continuity of care. Staffing levels are kept under review and the changing needs and dependency levels of the people living in the home are re-evaluated regularly. Staff receive relevant basic training and have the opportunity to undertake National Vocational Qualifications. EVIDENCE: We were pleased to note the home now has a more permanent staff team, which has helped to provide a more supportive environment. People have been recruited for the home’s remaining vacancies. The current staffing of the home is for four staff to be on duty on each shift, and a senior staff member as the shift leader. We discussed with the Manager the current level of dependency and there are a small number of fairly independent people in the home. She uses a dependency tool to keep the level of needs under review and is aware that, if the home’s vacancies are filled, or the more independent people move out, this could affect the staffing levels that are required. The records of three of the newer staff were examined. The information required to help safeguard the people living in the home was all in place, including Criminal Records Bureau disclosure numbers, references and information on the right to work. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 20 We were pleased to note that the home has a good percentage of the staff with National Vocational Qualifications, including 50 of the permanent care staff team. The Manager, Deputy Manager and one senior have National Vocational Qualification Level 4, six staff members have Level 3 and two have Level 2. Two of the regular relief staff have Level 3. Ten of the staff are currently undertaking the qualification. The Manager provided a “matrix” of staff training dates. While this showed that most of the training was current, there were some gaps. The Manager was asked to ensure that the records reflect all of the training the staff have accessed. Eight of the staff had completed their mandatory induction training in 2006 or 2007 which includes health and safety, manual handling, food hygiene, safeguarding adults, first aid and infection control. Use is made of the training offered by the London Borough of Hounslow. The next company training programme was in the process of being finalised and the Manager said that she would put forward those needing updated training. Most people had attended training on care planning and review, although not all had mental health and dementia training. Ten staff have been trained as first aiders. All of the staff who were in post in 2007 have had equality and diversity training and those commencing in 2008 will be required to attend this. Staff were positive about the training on offer. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 21 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. More thorough health and safety monitoring is in place, and better record keeping is aiding this process. The Manager has shown she has the experience and competency to manage the home and is gaining the required qualifications. The Annual Quality Assurance Assessment has clear information regarding the home and the outcomes for the people living there. EVIDENCE: The Manager has been registered with the Commission for Social Care Inspection and has made great efforts to reduce the number of requirements that have been made at past inspections. She is supported by the Assistant Manager and three Senior Support staff and a team of support workers. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 22 She has a Diploma in Nursing and has completed the National Vocational Qualification Level 4. She has now commenced the Registered Managers Award. We felt that the changes to the home’s environment and systems have improved the general ethos of the home. However, there have continued to be anonymous complaints made. which are being dealt with by the Registered Providers, but need to be addressed through staff meetings and supervision. The Manager completed the Commission for Social Care Inspection’s Annual Quality Assurance Assessment Quality audit which provided us with information about the home and the way in which it intended to improve. Any barriers to improvement are also noted. This was completed in September 2007, some months prior to this inspection, and many of the planned improvements have been carried out. People living in the home have been recently surveyed about their views and copies of the surveys were seen. Regular Regulation 26 visits are carried out and one was undertaken during the inspection. The Manager was asked to ensure that these are passed to us on a regular basis to support the monitoring of the home. The latest one was examined and the person completing the monitoring visit provided the Manager with an Action Plan to compete, with timescales. Staff are regularly supervised, with a target of six supervisions a year. One record was seen to evidence that regular bank staff also receive supervision. A new annual appraisal system is being introduced, which will begin with the Manager being appraised and then “cascaded” though the staff team. We examined a sample of the four financial records and monies held in the home and found that they were generally in good order. A small discrepancy found was rectified immediately as staff were aware the receipt had not yet been put in the wallet. Regular monitoring checks are carried out on a percentage of the records each week. The majority of people living in the home have their money managed by their families and only small sums are kept for hairdressing, newspapers or other small personal items. We noted that there are safety protection systems in place. The staff are alerted, through the computer system, when health and safety maintenance and checks are required. A list was provided which showed those which were up-to-date, those about to become due, and those overdue At the time the list was provided, the monthly water temperatures and the monthly lift maintenance were overdue from March and February respectively. All of the other weekly and monthly checks had been carried out, as had the threemonthly and six-monthly. The annual checks, such as the fire extinguishers, fire alarm systems, gas inspection and portable electrical testing, had been carried out in the last year as required. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 23 We noted several improvements in the record keeping in the home although the fire records were not all completed. The fire risk assessment was not available at the first day of the inspection, although it has been produced. The Manager provided the action plan for completing the outstanding requirements. Some further information was needed regarding the people living in the home who smoke as they are allowed to do so in their rooms. The way in which the general risks around smoking are reduced needs to be included in the fire risk assessment and some further detail was required. At previous inspections, there had been problems with the storage of COSHH materials and, at the last inspection, there was poor storage in each unit. We were pleased to note that no inappropriate storage was seen on this inspection and lockable cupboards are now available in each unit. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 X 3 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 2 John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 12 (1)(a)(b) Requirement The Registered Manager must ensure that any identified health needs are fully recorded, and that there is full guidance and training in place to support the person and the staff. The Registered Manager must ensure that the risk assessments for each person are fully and appropriately detailed, dated and regularly reviewed. The Registered Manager must ensure that fire risk assessment is completed in full where there may be a risk when people smoke in their rooms. The general risk reduction precautions should be detailed and level of risk regularly reviewed. Timescale for action 31/05/08 2 OP8 13 (4) (b) (c) 31/05/08 3 OP38 13 (4) (b) (c) 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard OP18 Good Practice Recommendations That further discussions take place on whistle blowing with the staff team to ensure that, if there are concerns, they are taken through the appropriate channels. John Collin House DS0000022891.V361723.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 John Collin House DS0000022891.V361723.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!